MEDICARE: DR. MISTY M GINICOLA PH.D., LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	002631	CT

General Provider Information

NPI Number	:	1366989816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MISTY M GINICOLA PH.D., LPC

Provider Business Mailing Address
First Line	:	672 W MAIN ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4826
Country	:	US
Telephone Number	:	203-339-1062
Fax Number	:

Provider Business Practice Location Address
First Line	:	672 W MAIN ST
Second Line	:
City	:	WEST HAVEN
State	:	CT
Zip	:	06516-4826
Country	:	US
Telephone Number	:	203-339-1062
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2017
Last Update Date	:	01/23/2017

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