Provider Demographics
NPI:1366989816
Name:GINICOLA, MISTY M (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:M
Last Name:GINICOLA
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4826
Mailing Address - Country:US
Mailing Address - Phone:203-339-1062
Mailing Address - Fax:
Practice Address - Street 1:672 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4826
Practice Address - Country:US
Practice Address - Phone:203-339-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002631101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health