Provider Demographics
NPI:1114368180
Name:MELLOR, INGRID (LCAT)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:MELLOR
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 PUTNAM AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-1003
Mailing Address - Country:US
Mailing Address - Phone:908-240-1462
Mailing Address - Fax:
Practice Address - Street 1:29 W 36TH ST STE 5E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7907
Practice Address - Country:US
Practice Address - Phone:908-240-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002051221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist