Provider Demographics
NPI:1851694244
Name:MODUGNO, ELIZABETH V (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:V
Last Name:MODUGNO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-3511
Mailing Address - Country:US
Mailing Address - Phone:203-383-0501
Mailing Address - Fax:
Practice Address - Street 1:8 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3511
Practice Address - Country:US
Practice Address - Phone:203-383-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0079741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003745Medicaid
CT004041000Medicaid
CT008042700Medicaid