Provider Demographics
NPI:1629069711
Name:MELLINGER, MARK V (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:V
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 WARBURTON AVENUE
Mailing Address - Street 2:APT. 9T
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1018
Mailing Address - Country:US
Mailing Address - Phone:914-613-4840
Mailing Address - Fax:
Practice Address - Street 1:680 W END AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6815
Practice Address - Country:US
Practice Address - Phone:212-864-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-29
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006704-1103TC0700X
CT002093103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00685456Medicaid
NY145203000OtherMIS
NY00685456Medicaid