Provider Demographics
NPI:1457177099
Name:STAGON, CORAL ELISE
Entity type:Individual
Prefix:
First Name:CORAL
Middle Name:ELISE
Last Name:STAGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORAL
Other - Middle Name:ELISE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36 SNAKE MEADOW HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOOSUP
Mailing Address - State:CT
Mailing Address - Zip Code:06354-1925
Mailing Address - Country:US
Mailing Address - Phone:860-377-8386
Mailing Address - Fax:
Practice Address - Street 1:36 SNAKE MEADOW HILL RD
Practice Address - Street 2:
Practice Address - City:MOOSUP
Practice Address - State:CT
Practice Address - Zip Code:06354-1925
Practice Address - Country:US
Practice Address - Phone:860-377-8386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician