Provider Demographics
NPI:1861636391
Name:MOYOSORE PAUPAU, LLC
Entity Type:Organization
Organization Name:MOYOSORE PAUPAU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOYSORE
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUPAU-MICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-496-2074
Mailing Address - Street 1:39 GLENBROOK RD
Mailing Address - Street 2:5Z
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2968
Mailing Address - Country:US
Mailing Address - Phone:203-496-2074
Mailing Address - Fax:203-355-2667
Practice Address - Street 1:860 CANAL ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-6953
Practice Address - Country:US
Practice Address - Phone:203-496-2074
Practice Address - Fax:203-355-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0064661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty