Healthcare Provider Details

I. General information

NPI: 1467004978
Provider Name (Legal Business Name): WENONA JEAN MELLOTT BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 GATEWAY DR
SLIDELL LA
70461-5589
US

IV. Provider business mailing address

350 GATEWAY DR
SLIDELL LA
70461-5589
US

V. Phone/Fax

Practice location:
  • Phone: 985-707-1410
  • Fax: 985-707-1415
Mailing address:
  • Phone: 985-707-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number18234
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: