Individual
DR. MICHAEL JACK MELLOTT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ED.D.
Contact information
Practice address
3509 S DYLAN ST, FLAGSTAFF, AZ 86001-9137
(928) 774-4658
(928) 774-4658
Mailing address
3509 S DYLAN ST, FLAGSTAFF, AZ 86001-9137
(928) 774-4658
(928) 774-4658
Taxonomy
Speciality
Code
Description
License number
State
103TS0200X
School Psychologist
Primary
3598
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
913039
AHCCCS PROVIDER NUMBER
AZ
Enumeration date
12/20/2006
Last updated
07/08/2007
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