Provider Demographics
NPI:1578123659
Name:CAPOTORTO, KIERSTEN ANNE-MOORE
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:ANNE-MOORE
Last Name:CAPOTORTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6617
Mailing Address - Country:US
Mailing Address - Phone:475-224-1175
Mailing Address - Fax:
Practice Address - Street 1:73 ELM ST
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-2340
Practice Address - Country:US
Practice Address - Phone:203-843-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CT144091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty