Provider Demographics
NPI:1558436915
Name:MELLOW, RICHARD G (MSEDS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:G
Last Name:MELLOW
Suffix:
Gender:M
Credentials:MSEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 BURNSIDE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3512
Mailing Address - Country:US
Mailing Address - Phone:860-289-1956
Mailing Address - Fax:860-289-1222
Practice Address - Street 1:527 BURNSIDE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3512
Practice Address - Country:US
Practice Address - Phone:860-289-1956
Practice Address - Fax:860-289-1222
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000380101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional