Provider Demographics
NPI:1043007818
Name:DOBLACK-MELLUM, STEPHANIE KAMILA (BS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KAMILA
Last Name:DOBLACK-MELLUM
Suffix:
Gender:
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 GAINES SCHOOL RD APT 213
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-6300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-5004
Practice Address - Country:US
Practice Address - Phone:706-542-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health