Provider Demographics
NPI:1033295944
Name:MELLINGER, CHARLES L (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HATHAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1416
Mailing Address - Country:US
Mailing Address - Phone:978-922-2280
Mailing Address - Fax:978-927-1758
Practice Address - Street 1:23 BROADWAY
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4417
Practice Address - Country:US
Practice Address - Phone:978-922-2280
Practice Address - Fax:978-927-1758
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health