Provider Demographics
NPI:1689272155
Name:MELLO, CODY W
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:MELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CODY
Other - Middle Name:W
Other - Last Name:MELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1255 KENDALL RD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2180 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4558
Practice Address - Country:US
Practice Address - Phone:805-461-6083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health