Provider Demographics
NPI:1912487729
Name:MELLONI, MARY JO (LICSW,MSW)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:MELLONI
Suffix:
Gender:F
Credentials:LICSW,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAUREEN DR
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-3621
Mailing Address - Country:US
Mailing Address - Phone:978-851-5834
Mailing Address - Fax:
Practice Address - Street 1:139 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-2725
Practice Address - Country:US
Practice Address - Phone:978-640-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1053121041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool