MEDICARE: MICHAEL W MELLON PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6611	OH
2	103TC2200X	Clinical Child & Adolescent Psychologist	LP4195	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	680011889	OTHER	MN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023088804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL W MELLON PHD

Provider Business Mailing Address
First Line	:	3333 BURNET AVENUE
Second Line	:	ML 3015
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3039
Country	:	US
Telephone Number	:	513-636-4336
Fax Number	:	513-636-3677

Provider Business Practice Location Address
First Line	:	3333 BURNET AVENUE
Second Line	:	ML 5021
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3039
Country	:	US
Telephone Number	:	513-636-4225
Fax Number	:	513-636-2511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	03/31/2010

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Directions to “ MICHAEL W MELLON PHD” Practice Location

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