Provider Demographics
NPI:1629158076
Name:PRIETO-MELLOY, MARTHA E (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:PRIETO-MELLOY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2416
Mailing Address - Country:US
Mailing Address - Phone:317-536-7100
Mailing Address - Fax:317-536-7101
Practice Address - Street 1:1431 N DELAWARE ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2416
Practice Address - Country:US
Practice Address - Phone:317-536-7100
Practice Address - Fax:317-536-7101
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005552A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN100270530AMedicaid