Provider Demographics
NPI:1225469059
Name:ALICEA, IVELISE
Entity Type:Individual
Prefix:
First Name:IVELISE
Middle Name:
Last Name:ALICEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-2602
Mailing Address - Country:US
Mailing Address - Phone:203-330-6000
Mailing Address - Fax:
Practice Address - Street 1:46 ALBION ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2602
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-339-7193
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical