Healthcare Provider Details

I. General information

NPI: 1699101956
Provider Name (Legal Business Name): GEOFFREY MELLON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

IV. Provider business mailing address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax: 310-204-4134
Mailing address:
  • Phone: 310-836-1223
  • Fax: 310-204-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW88540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: