Provider Demographics
NPI:1407540495
Name:CIVITELLO, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CIVITELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 NORWICH NEW LONDON TPKE STE 5
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-1908
Mailing Address - Country:US
Mailing Address - Phone:860-848-0514
Mailing Address - Fax:860-848-0523
Practice Address - Street 1:912 NORWICH NEW LONDON TPKE STE 5
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-1908
Practice Address - Country:US
Practice Address - Phone:860-848-0514
Practice Address - Fax:860-848-0523
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician