Provider Demographics
NPI:1184860553
Name:MELLINKOFF, ALBERT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:MELLINKOFF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4284
Mailing Address - Country:US
Mailing Address - Phone:310-746-8427
Mailing Address - Fax:888-340-4596
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4284
Practice Address - Country:US
Practice Address - Phone:310-746-8427
Practice Address - Fax:888-340-4596
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23767103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEG935AOtherMEDICARE PTAN