Provider Demographics
NPI:1295576197
Name:NELSON MELLE, VIVIAN (MC, LAC)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:NELSON MELLE
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4648 E PALM LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4144
Mailing Address - Country:US
Mailing Address - Phone:623-451-4800
Mailing Address - Fax:
Practice Address - Street 1:1250 W WASHINGTON ST STE 215
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-1697
Practice Address - Country:US
Practice Address - Phone:602-842-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional