Provider Demographics
NPI:1760546147
Name:MELLOTT, MICHAEL JACK (EDD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JACK
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 S DYLAN ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9137
Mailing Address - Country:US
Mailing Address - Phone:928-774-4658
Mailing Address - Fax:928-774-4658
Practice Address - Street 1:3509 S DYLAN ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-9137
Practice Address - Country:US
Practice Address - Phone:928-774-4658
Practice Address - Fax:928-774-4658
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3598103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ913039OtherAHCCCS PROVIDER NUMBER