Basic Information
| Provider Information | |||||||||
| NPI: | 1790105823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLUM | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 MAPLE AVE. | ||||||||
| Address2: | |||||||||
| City: | BELLE FONTAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375991975 | ||||||||
| FaxNumber: | 9375992769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1302519 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.