Healthcare Provider Details

I. General information

NPI: 1992767347
Provider Name (Legal Business Name): MELISSA ABLES WILSON JACOB L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 ESSEX PL
STRATFORD CT
06615-5850
US

IV. Provider business mailing address

1129 ESSEX PL
STRATFORD CT
06615-5850
US

V. Phone/Fax

Practice location:
  • Phone: 203-375-8140
  • Fax: 203-375-8050
Mailing address:
  • Phone: 203-375-8140
  • Fax: 203-375-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005167
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: