Healthcare Provider Details

I. General information

NPI: 1689945438
Provider Name (Legal Business Name): MELODIE KEEN LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELODIE HAMMER LMFT

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 BYINGTON PL
NORWALK CT
06850-3309
US

IV. Provider business mailing address

350 FAIRFIELD AVE SUITE 701
BRIDGEPORT CT
06604-6014
US

V. Phone/Fax

Practice location:
  • Phone: 203-866-2541
  • Fax: 203-854-5682
Mailing address:
  • Phone: 203-336-5225
  • Fax: 203-336-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000402
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00723
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: