Provider Demographics
NPI:1598479917
Name:MINICHIELLO, DEIRDRE
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:MINICHIELLO
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04231-0095
Mailing Address - Country:US
Mailing Address - Phone:978-886-6693
Mailing Address - Fax:
Practice Address - Street 1:123 LITTLEFIELD RD
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:ME
Practice Address - Zip Code:04231-3143
Practice Address - Country:US
Practice Address - Phone:978-886-6693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC6728101YP2500X
MA7105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional