Provider Demographics
NPI:1528344181
Name:MELLBLOM, CARON IVY (MS)
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:IVY
Last Name:MELLBLOM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 FINNELL WAY
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-4445
Mailing Address - Country:US
Mailing Address - Phone:714-402-8415
Mailing Address - Fax:
Practice Address - Street 1:928 FINNELL WAY
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-4445
Practice Address - Country:US
Practice Address - Phone:714-402-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110093972235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110093972OtherSPEECH PATHOLOGIST