Provider Demographics
NPI:1457970576
Name:MITZKOVITZ, CAYLA
Entity type:Individual
Prefix:
First Name:CAYLA
Middle Name:
Last Name:MITZKOVITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 OTROBANDO AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2116
Mailing Address - Country:US
Mailing Address - Phone:860-889-7274
Mailing Address - Fax:
Practice Address - Street 1:1280 E CAMPUS DR BLDG 1101
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3803
Practice Address - Country:US
Practice Address - Phone:989-774-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5096103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherDOCTORAL STUDENT