Provider Demographics
NPI:1699081844
Name:DEMELLO, COLLEEN (LPC, BCBA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:DEMELLO
Suffix:
Gender:F
Credentials:LPC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:IVORYTON
Mailing Address - State:CT
Mailing Address - Zip Code:06442-1242
Mailing Address - Country:US
Mailing Address - Phone:860-388-7575
Mailing Address - Fax:860-767-1532
Practice Address - Street 1:160 WEST ST
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2441
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:860-613-9952
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001258101YP2500X
CT1-03-1264103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst