Provider Demographics
NPI:1013311554
Name:MICCICHE, CHELSEY
Entity Type:Individual
Prefix:MS
First Name:CHELSEY
Middle Name:
Last Name:MICCICHE
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 1:34 MURRAY STREET
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710
Mailing Address - Country:US
Mailing Address - Phone:203-756-8317
Mailing Address - Fax:203-756-8310
Practice Address - Street 1:33 PRATT ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1014
Practice Address - Country:US
Practice Address - Phone:860-946-0447
Practice Address - Fax:860-430-6861
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
CT5020101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program