1154959336 NPI number — JACQUELYN M MELLIS LCSW

Table of content: JACQUELYN M MELLIS LCSW (NPI 1154959336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154959336 NPI number — JACQUELYN M MELLIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLIS
Provider First Name:
JACQUELYN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154959336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8534 SAGAMORE DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR HILL
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-288-9737
Provider Business Mailing Address Fax Number:
636-274-9332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2634 HWY 109
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
WILDWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-384-6534
Provider Business Practice Location Address Fax Number:
636-274-9332
Provider Enumeration Date:
04/01/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  001252 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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