Provider Demographics
NPI:1134815723
Name:MASTROGIOVANNI, KELLIE ANN (LBA)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:ANN
Last Name:MASTROGIOVANNI
Suffix:
Gender:
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 LAUREL HILL RD APT 8
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-5714
Mailing Address - Country:US
Mailing Address - Phone:860-459-9717
Mailing Address - Fax:
Practice Address - Street 1:276 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3022
Practice Address - Country:US
Practice Address - Phone:475-414-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CT2075103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician