Provider Demographics
NPI:1275545691
Name:MELLOTT, SUSAN LYNN (LSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35888 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3086
Mailing Address - Country:US
Mailing Address - Phone:440-327-1800
Mailing Address - Fax:440-327-1533
Practice Address - Street 1:35888 CENTER RIDGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3086
Practice Address - Country:US
Practice Address - Phone:440-327-1800
Practice Address - Fax:440-327-1533
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-0001784104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker