Provider Demographics
NPI:1073009320
Name:CASPARIUS, STACEY L
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:CASPARIUS
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 1:2425 POST RD STE 206
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1267
Mailing Address - Country:US
Mailing Address - Phone:203-970-7896
Mailing Address - Fax:
Practice Address - Street 1:2425 POST RD STE 206
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1267
Practice Address - Country:US
Practice Address - Phone:203-970-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid