Provider Demographics
NPI:1346874773
Name:CAPOBIANCO, KRISTA M (LCSW-A)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:M
Last Name:CAPOBIANCO
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:MISS
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:LIPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1190 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2818
Mailing Address - Country:US
Mailing Address - Phone:704-296-6200
Mailing Address - Fax:
Practice Address - Street 1:1190 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2818
Practice Address - Country:US
Practice Address - Phone:704-296-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0139771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherN/A