Provider Demographics
NPI:1043428824
Name:MELLEN, HENRY S (PHD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:S
Last Name:MELLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-3124
Mailing Address - Country:US
Mailing Address - Phone:650-714-4675
Mailing Address - Fax:650-329-1579
Practice Address - Street 1:851 FREMONT AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5698
Practice Address - Country:US
Practice Address - Phone:650-989-1256
Practice Address - Fax:650-329-1579
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20759103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist