Basic Information
| Provider Information | |||||||||
| NPI: | 1669894655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAPUTO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PELLEGRINO | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3006 DORLON PL | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115104409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163222030 | ||||||||
| FaxNumber: | 7186418931 | ||||||||
| Practice Location | |||||||||
| Address1: | 13002 115TH AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH OZONE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114202122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186418933 | ||||||||
| FaxNumber: | 7186418931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2014 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 087681 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 084338-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.