Provider Demographics
NPI:1124145727
Name:CORETTO, CHARLES JR (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CORETTO
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4710
Mailing Address - Country:US
Mailing Address - Phone:203-748-0848
Mailing Address - Fax:120-378-8188
Practice Address - Street 1:405 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4710
Practice Address - Country:US
Practice Address - Phone:203-748-0848
Practice Address - Fax:120-378-8188
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007239101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003522Medicaid