Healthcare Provider Details

I. General information

NPI: 1023088804
Provider Name (Legal Business Name): MICHAEL W MELLON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVENUE ML 5021
CINCINNATI OH
45229-3039
US

IV. Provider business mailing address

3333 BURNET AVENUE ML 3015
CINCINNATI OH
45229-3039
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4225
  • Fax: 513-636-2511
Mailing address:
  • Phone: 513-636-4336
  • Fax: 513-636-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6611
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP4195
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: