Provider Demographics
NPI:1972619310
Name:YETSO, MELISSA JAYNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JAYNE
Last Name:YETSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JAYNE
Other - Last Name:LIPUMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:24 FAIRY DELL RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413
Mailing Address - Country:US
Mailing Address - Phone:860-669-2060
Mailing Address - Fax:203-483-5432
Practice Address - Street 1:225 MONTOWESE ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3873
Practice Address - Country:US
Practice Address - Phone:203-619-1664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0044501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004230439Medicaid
CTP2749520OtherOXFORD
CT004230439Medicaid