Healthcare Provider Details

I. General information

NPI: 1750122412
Provider Name (Legal Business Name): GRACE C MELLOY INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 ELM ST NE
ALBUQUERQUE NM
87102-3672
US

IV. Provider business mailing address

239 ELM ST NE
ALBUQUERQUE NM
87102-3672
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-2695
  • Fax:
Mailing address:
  • Phone: 505-242-1010
  • Fax: 505-243-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0783
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: