Provider Demographics
NPI:1720640964
Name:GEORGETTI, CAROLINE (LIC AC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:GEORGETTI
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CLIPPER DR
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1996
Mailing Address - Country:US
Mailing Address - Phone:860-326-4335
Mailing Address - Fax:
Practice Address - Street 1:38 E MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2807
Practice Address - Country:US
Practice Address - Phone:860-464-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT43000753171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist