Provider Demographics
NPI:1437203577
Name:CAPOBIANCO, KELLY (ATC,CSCS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:CAPOBIANCO
Suffix:
Gender:F
Credentials:ATC,CSCS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DETWILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:ONECO
Mailing Address - State:CT
Mailing Address - Zip Code:06373-0265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 PLAINFIELD PIKE
Practice Address - Street 2:
Practice Address - City:ONECO
Practice Address - State:CT
Practice Address - Zip Code:06373
Practice Address - Country:US
Practice Address - Phone:860-690-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT146561574174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist