MEDICARE: DEIRDRE MINICHIELLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	CC6728	ME
2	101YM0800X	Mental Health Counselor	7105	MA

General Provider Information

NPI Number	:	1598479917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRE MINICHIELLO

Provider Business Mailing Address
First Line	:	PO BOX 95
Second Line	:
City	:	STONEHAM
State	:	ME
Zip	:	04231-0095
Country	:	US
Telephone Number	:	978-886-6693
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 LITTLEFIELD RD
Second Line	:
City	:	STONEHAM
State	:	ME
Zip	:	04231-3143
Country	:	US
Telephone Number	:	978-886-6693
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2023
Last Update Date	:	01/10/2023

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Directions to “ DEIRDRE MINICHIELLO ” Practice Location

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