Provider Demographics
NPI:1962190470
Name:MELLAL, EMILIE ANN GERVAIS (MA, INTERN)
Entity type:Individual
Prefix:MS
First Name:EMILIE
Middle Name:ANN GERVAIS
Last Name:MELLAL
Suffix:
Gender:F
Credentials:MA, INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ELDER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-3878
Mailing Address - Country:US
Mailing Address - Phone:508-713-7131
Mailing Address - Fax:
Practice Address - Street 1:6 ELDER ST APT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02125-3878
Practice Address - Country:US
Practice Address - Phone:508-713-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist