Provider Demographics
NPI:1427255355
Name:CAPICCHIONI, CHARLES (MALLP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CAPICCHIONI
Suffix:
Gender:M
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 HIDDEN HBR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2111
Mailing Address - Country:US
Mailing Address - Phone:248-470-9018
Mailing Address - Fax:
Practice Address - Street 1:29260 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1161
Practice Address - Country:US
Practice Address - Phone:248-355-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012712103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent