Provider Demographics
NPI:1114551124
Name:MAGNOTTA, MICHAEL ROCCO (BCABA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROCCO
Last Name:MAGNOTTA
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 W MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-2560
Practice Address - Country:US
Practice Address - Phone:203-283-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1283103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1-21-53025OtherBOARD CERTIFIED BEHAVIOR ANALYST