Provider Demographics
NPI:1942461090
Name:PAUPAU MICKENS, MOYOSORE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MOYOSORE
Middle Name:
Last Name:PAUPAU MICKENS
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 1:61 ROCK SPRING ROAD
Mailing Address - Street 2:#36
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906
Mailing Address - Country:US
Mailing Address - Phone:203-496-2074
Mailing Address - Fax:
Practice Address - Street 1:61 ROCK SPRING ROAD
Practice Address - Street 2:#36
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06906
Practice Address - Country:US
Practice Address - Phone:203-496-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-21
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CT0064661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator