Healthcare Provider Details

I. General information

NPI: 1679485940
Provider Name (Legal Business Name): COLETTE OLIVIA VICINANZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 FORT EDDY RD STE 1
CONCORD NH
03301-7415
US

IV. Provider business mailing address

30 ALBIN RD
BOW NH
03304-3702
US

V. Phone/Fax

Practice location:
  • Phone: 630-484-8497
  • Fax:
Mailing address:
  • Phone: 630-484-8497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number253
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: