Basic Information
| Provider Information | |||||||||
| NPI: | 1023088804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVENUE | ||||||||
| Address2: | ML 3015 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364336 | ||||||||
| FaxNumber: | 5136363677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVENUE | ||||||||
| Address2: | ML 5021 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
| FaxNumber: | 5136362511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6611 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | LP4195 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 811579600 | 05 | MN | MEDICAID | 680011889 | 01 | MN | RAILROAD MEDICARE | OTHER |