Provider Demographics
NPI:1750626032
Name:COSTANZO, MELISSA LEIGH (LMFT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LEIGH
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 TOWER AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1273
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:860-714-8591
Practice Address - Street 1:675 TOWER AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1273
Practice Address - Country:US
Practice Address - Phone:860-714-2750
Practice Address - Fax:860-714-8591
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00930106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist