1992080105 NPI number — MS. KRISTIN HOLDT PRACITTO LCSW

Table of content: SHANNON MIXON (NPI 1548883150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992080105 NPI number — MS. KRISTIN HOLDT PRACITTO LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRACITTO
Provider First Name:
KRISTIN
Provider Middle Name:
HOLDT
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLDT
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992080105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 E MAIN ST
Provider Second Line Business Mailing Address:
4TH FLOOR ADMINISTRATION
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06702-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-9000
Provider Business Mailing Address Fax Number:
203-574-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 E MAIN ST
Provider Second Line Business Practice Location Address:
WATERBURY OP ADULT SERVICES
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-755-1143
Provider Business Practice Location Address Fax Number:
203-753-3274
Provider Enumeration Date:
10/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  004542 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/UNITED HEALTHCARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 10450310 WATERBURY . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 574044 PENDING . This is a "MHN TRICARENORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "ANTHEM BCBS OF CT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "AETNA BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 574044 PENDING . This is a "MHN MANAGED HEALTN NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13752330 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 00803733 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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