Provider Demographics
NPI:1346305596
Name:FANELLO DIAZ, MARCY MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARCY
Middle Name:MARIE
Last Name:FANELLO DIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARCY
Other - Middle Name:MARIE
Other - Last Name:BIANCHINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:124 COURT ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3333
Mailing Address - Country:US
Mailing Address - Phone:860-807-3752
Mailing Address - Fax:
Practice Address - Street 1:124 COURT ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3333
Practice Address - Country:US
Practice Address - Phone:860-807-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical