Provider Demographics
NPI:1992931695
Name:DIBELLA, COLLEEN M (LCSW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:DIBELLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2609
Mailing Address - Country:US
Mailing Address - Phone:860-662-1641
Mailing Address - Fax:860-760-6585
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:STE 300
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1901
Practice Address - Country:US
Practice Address - Phone:860-662-1641
Practice Address - Fax:860-760-6585
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT261803133Medicaid