Provider Demographics
NPI:1659722544
Name:MELLON, MAUREEN G
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:G
Last Name:MELLON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MAUREEN
Other - Middle Name:G
Other - Last Name:MELLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:48 KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-1010
Mailing Address - Country:US
Mailing Address - Phone:973-715-4559
Mailing Address - Fax:
Practice Address - Street 1:543 VALLEY RD
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1881
Practice Address - Country:US
Practice Address - Phone:973-715-4559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00351000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ16597223544OtherCIGNA
1659722544OtherOXFORD
1659722544OtherUNITED HEALTHCARE
NJ1659722544OtherOPTUM
1659722544OtherCIGNA
1659722544OtherHBCBS
NJ1659722544OtherAETNA
1659722544OtherBEACON HEALTH