Provider Demographics
NPI:1710244785
Name:SABINO, MIRTA
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:SABINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRTA
Other - Middle Name:MICAELA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 STONEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705
Mailing Address - Country:US
Mailing Address - Phone:203-525-4594
Mailing Address - Fax:
Practice Address - Street 1:126 STONEFIELD DR
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705
Practice Address - Country:US
Practice Address - Phone:203-525-4594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT101Y00000XMedicaid