Provider Demographics
NPI:1760751390
Name:MELLON-KETCHUM, CATHERINE (CSC-AD)
Entity Type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:
Last Name:MELLON-KETCHUM
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 KATE WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6957
Mailing Address - Country:US
Mailing Address - Phone:410-848-2500
Mailing Address - Fax:410-876-3016
Practice Address - Street 1:98 N COURT ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-9300
Practice Address - Country:US
Practice Address - Phone:410-848-6100
Practice Address - Fax:410-876-5187
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC1435101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420658400Medicaid