Provider Demographics
NPI:1376850859
Name:MELLON, RYAN DREW (LCSW-R)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DREW
Last Name:MELLON
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W DOMINICK ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5859
Mailing Address - Country:US
Mailing Address - Phone:315-336-6230
Mailing Address - Fax:315-337-9262
Practice Address - Street 1:227 W DOMINICK ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5859
Practice Address - Country:US
Practice Address - Phone:315-336-6230
Practice Address - Fax:315-338-9262
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078848104100000X
NY0817221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker