Provider Demographics
NPI:1437376597
Name:DIVITO, MELISSA P (MS, LPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:P
Last Name:DIVITO
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 TRI MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-2311
Mailing Address - Country:US
Mailing Address - Phone:860-349-3884
Mailing Address - Fax:
Practice Address - Street 1:11 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3656
Practice Address - Country:US
Practice Address - Phone:860-704-0300
Practice Address - Fax:860-343-9144
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000084101YA0400X
CT000550101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional