Provider Demographics
NPI:1447819347
Name:DICELLO, MELANIE M (LCSW)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:M
Last Name:DICELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:M
Other - Last Name:WAMBOLDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:W231N1440 CORPORATE CT STE 310
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1503
Mailing Address - Country:US
Mailing Address - Phone:414-773-4312
Mailing Address - Fax:
Practice Address - Street 1:W231N1440 CORPORATE CT STE 310
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1503
Practice Address - Country:US
Practice Address - Phone:414-773-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI92191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100091699Medicaid