Provider Demographics
NPI:1124681572
Name:MELLON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16780 W CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-3340
Mailing Address - Country:US
Mailing Address - Phone:714-393-9136
Mailing Address - Fax:
Practice Address - Street 1:530 E 11TH ST UNIT 5
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2014
Practice Address - Country:US
Practice Address - Phone:714-393-9136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-23-65782103K00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst