Provider Demographics
NPI:1972586535
Name:MELLIN, MARY BETH (MSW LMSW ACSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:MELLIN
Suffix:
Gender:F
Credentials:MSW LMSW ACSW
Other - Prefix:
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:KNAPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:580 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3985
Mailing Address - Fax:906-225-4562
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3985
Practice Address - Fax:906-225-4562
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010685231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOE26040032Medicare ID - Type Unspecified