Provider Demographics
NPI:1376348995
Name:MELLON, CAROLINE (BS)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17505 N 79TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8724
Mailing Address - Country:US
Mailing Address - Phone:602-989-8899
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8724
Practice Address - Country:US
Practice Address - Phone:602-989-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSLG13230101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1740851542OtherJANUARY HARTZE INDIVIDUAL NPI
AZ1801623228OtherCENTERPOINTE NPI
AZ1043982747OtherARROWHEAD NPI
AZ203827Medicaid
AZ180298Medicaid