Provider Demographics
NPI:1073674776
Name:CAPPUCCIO, KENNETH THOMAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:THOMAS
Last Name:CAPPUCCIO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 HAYSTACK WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3276
Mailing Address - Country:US
Mailing Address - Phone:908-447-2913
Mailing Address - Fax:
Practice Address - Street 1:2195 HAYSTACK WAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3276
Practice Address - Country:US
Practice Address - Phone:908-447-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC147491041C0700X
NJ44SC045331001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
274527OtherMHN
5907728OtherAETNA
465949000OtherMAGELLAN ICE
477445OtherVALUE OPTIONS