Provider Demographics
NPI:1083680359
Name:MELLOTT, STEPHEN (LCSWC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10435 DOWNSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1732
Mailing Address - Country:US
Mailing Address - Phone:301-766-8423
Mailing Address - Fax:
Practice Address - Street 1:10435 DOWNSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-1732
Practice Address - Country:US
Practice Address - Phone:301-766-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD104891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD986965400Medicaid
MDHE02Medicare ID - Type Unspecified