Provider Demographics
NPI:1760561237
Name:CAPOZZOLI, GEORGE M (MA)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:M
Last Name:CAPOZZOLI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 W RIDGE RD
Mailing Address - Street 2:SUITE B-43
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1879
Mailing Address - Country:US
Mailing Address - Phone:814-838-9155
Mailing Address - Fax:814-838-9097
Practice Address - Street 1:3939 W RIDGE RD
Practice Address - Street 2:SUITE B-43
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1879
Practice Address - Country:US
Practice Address - Phone:814-838-9155
Practice Address - Fax:814-838-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004658-L103T00000X
PAMF000142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA517569Medicare UPIN
PA700369Medicare UPIN