Healthcare Provider Details

I. General information

NPI: 1457608804
Provider Name (Legal Business Name): MELLOW PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2012
Last Update Date: 08/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PIER AVE SUITE 424
HERMOSA BEACH CA
90254-3608
US

IV. Provider business mailing address

200 PIER AVE SUITE 424
HERMOSA BEACH CA
90254-3608
US

V. Phone/Fax

Practice location:
  • Phone: 800-593-2560
  • Fax: 800-593-2560
Mailing address:
  • Phone: 800-593-2560
  • Fax: 800-593-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23911
License Number StateCA

VIII. Authorized Official

Name: DR. COLLEEN F. LONG
Title or Position: OWNER
Credential: PSY.D.
Phone: 800-593-2560