Provider Demographics
NPI:1922755362
Name:MUFALLI, STEVEN DALLAS
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:DALLAS
Last Name:MUFALLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 PARK RD UNIT 2-8
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2357
Mailing Address - Country:US
Mailing Address - Phone:203-819-0264
Mailing Address - Fax:
Practice Address - Street 1:585 PARK RD UNIT 2-8
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2357
Practice Address - Country:US
Practice Address - Phone:203-819-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1410103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1851912745Medicaid