Provider Demographics
NPI:1043789142
Name:COLLELO-BIBEAU, JESSICA ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:COLLELO-BIBEAU
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:PO BOX 541
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-0541
Mailing Address - Country:US
Mailing Address - Phone:860-428-2249
Mailing Address - Fax:
Practice Address - Street 1:554 LIBERTY HWY STE 6
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2728
Practice Address - Country:US
Practice Address - Phone:860-412-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT091441041C0700X
CT91441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty