Provider Demographics
NPI:1558707471
Name:DICORPO, MICHELLE LEE (MS, MFT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LEE
Last Name:DICORPO
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 NEWFIELD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1846
Mailing Address - Country:US
Mailing Address - Phone:860-965-4072
Mailing Address - Fax:
Practice Address - Street 1:769 NEWFIELD ST STE 2
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-1846
Practice Address - Country:US
Practice Address - Phone:860-965-4072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001149Medicaid