Provider Demographics
NPI:1063627149
Name:LACILLA, KENNETH MICHAEL (MSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:LACILLA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 APPLETREE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2903
Mailing Address - Country:US
Mailing Address - Phone:203-288-7943
Mailing Address - Fax:
Practice Address - Street 1:476 HOWE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-3153
Practice Address - Country:US
Practice Address - Phone:203-924-9426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0049081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical