Provider Demographics
NPI:1285817528
Name:MELLUM, AMY ELIZABETH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:MELLUM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 SEMINARY AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-262-9726
Mailing Address - Fax:651-294-2347
Practice Address - Street 1:311 RAMSEY ST., SUITE 205
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-262-9726
Practice Address - Fax:651-294-2347
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN221928100Medicaid
MN09B85MEOtherBCBS OF MN
MNHP88034OtherHEALTH PARTNERS