Provider Demographics
NPI:1548354988
Name:MELLO, PAMELA TAYLOR (LMFT)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:TAYLOR
Last Name:MELLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 SHORELINE DRIVE SUITE A-4
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-406-4196
Mailing Address - Fax:209-472-7164
Practice Address - Street 1:7510 SHORELINE DRIVE SUITE A-4
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219
Practice Address - Country:US
Practice Address - Phone:209-406-4196
Practice Address - Fax:209-472-7164
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35219106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA219221968OtherUBH
CA550010002663OtherPBHI