Provider Demographics
NPI:1609972017
Name:CAPEZZUTO, MATTHEW ANTHONY (LISW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:CAPEZZUTO
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22540 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2212
Mailing Address - Country:US
Mailing Address - Phone:440-734-4037
Mailing Address - Fax:440-734-4710
Practice Address - Street 1:22540 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2212
Practice Address - Country:US
Practice Address - Phone:440-734-4037
Practice Address - Fax:440-734-4710
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2017-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI76231041C0700X
OH7071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2594518OtherMEDICAID PROVIDER REPORTING NUMBER
OH2594518OtherMEDICAID PROVIDER REPORTING NUMBER
OHS51112Medicare UPIN