Provider Demographics
NPI:1174662837
Name:RICCIO, KATHLEEN D (BS, CAC)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:D
Last Name:RICCIO
Suffix:
Gender:F
Credentials:BS, CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-4927
Mailing Address - Country:US
Mailing Address - Phone:203-736-2601
Mailing Address - Fax:203-736-2641
Practice Address - Street 1:435 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1964
Practice Address - Country:US
Practice Address - Phone:203-736-2601
Practice Address - Fax:203-736-2641
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCAC-4079101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)