Provider Demographics
NPI:1699101956
Name:MELLON, GEOFFREY (LCSW)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:MELLON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 MOTOR AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3710
Mailing Address - Country:US
Mailing Address - Phone:310-836-1223
Mailing Address - Fax:310-204-4134
Practice Address - Street 1:3200 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3710
Practice Address - Country:US
Practice Address - Phone:310-836-1223
Practice Address - Fax:310-204-4134
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW88540104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker