Provider Demographics
NPI:1760190052
Name:CAPEZZUTO, COLLEEN ANNE (LICENSED SCHOOL PSY)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANNE
Last Name:CAPEZZUTO
Suffix:
Gender:F
Credentials:LICENSED SCHOOL PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 OAK COMMON AVE
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-6805
Mailing Address - Country:US
Mailing Address - Phone:904-907-7489
Mailing Address - Fax:
Practice Address - Street 1:184 OAK COMMON AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-6805
Practice Address - Country:US
Practice Address - Phone:904-907-7489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
FLSS1538103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist