Provider Demographics
NPI:1164731287
Name:CAPOCASA, KELLI BRIDGET (MA, BCBA)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:BRIDGET
Last Name:CAPOCASA
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2344 HELEN ST N
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-2942
Practice Address - Country:US
Practice Address - Phone:651-773-5988
Practice Address - Fax:651-773-5978
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-08-4748103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst