Provider Demographics
NPI:1013742659
Name:DELICES, MICHELLE CARMENE (LAC INTERN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CARMENE
Last Name:DELICES
Suffix:
Gender:F
Credentials:LAC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BIRCH LN # 5C
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-5705
Mailing Address - Country:US
Mailing Address - Phone:347-296-5355
Mailing Address - Fax:
Practice Address - Street 1:99 WALLS ST N
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10005
Practice Address - Country:US
Practice Address - Phone:833-538-2735
Practice Address - Fax:631-201-3212
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor