Provider Demographics
NPI:1275873390
Name:PISCO, MICHAEL J (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:PISCO
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WALLS DRIVE
Mailing Address - Street 2:STE 206
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5163
Mailing Address - Country:US
Mailing Address - Phone:203-689-8989
Mailing Address - Fax:
Practice Address - Street 1:55 WALLS DRIVE
Practice Address - Street 2:STE 206
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5163
Practice Address - Country:US
Practice Address - Phone:203-689-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001481106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001481OtherLICENSED MARITAL AND FAMILY THERAPIST (L.M.F.T.)