Healthcare Provider Details

I. General information

NPI: 1568284461
Provider Name (Legal Business Name): MELISSA MARIE VIDEIRA MS, SYC, LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ENTERPRISE DR STE 415
SHELTON CT
06484-4631
US

IV. Provider business mailing address

315 SOUNDVIEW AVE
SHELTON CT
06484-2181
US

V. Phone/Fax

Practice location:
  • Phone: 203-255-5078
  • Fax: 203-295-7663
Mailing address:
  • Phone: 203-258-7175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7706
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: