Provider Demographics
NPI:1629493036
Name:MELINA MANSOUR LLC
Entity Type:Organization
Organization Name:MELINA MANSOUR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMFT
Authorized Official - Prefix:
Authorized Official - First Name:MELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:860-378-9605
Mailing Address - Street 1:1175 S MAIN ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:PLANTSVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06479-1690
Mailing Address - Country:US
Mailing Address - Phone:860-378-9605
Mailing Address - Fax:860-628-3966
Practice Address - Street 1:51 N MAIN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2537
Practice Address - Country:US
Practice Address - Phone:860-378-9605
Practice Address - Fax:860-328-3966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000462106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty