Provider Demographics
NPI:1366705881
Name:MELLOTT, KATRINA LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LYNN
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19311-9356
Mailing Address - Country:US
Mailing Address - Phone:215-370-1987
Mailing Address - Fax:484-720-8110
Practice Address - Street 1:220 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:PA
Practice Address - Zip Code:19311-9356
Practice Address - Country:US
Practice Address - Phone:215-370-1987
Practice Address - Fax:484-720-8110
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst