Provider Demographics
NPI:1669944468
Name:MAHLER, MELLISSA SORBELLO (LCSW,LMSW)
Entity type:Individual
Prefix:
First Name:MELLISSA
Middle Name:SORBELLO
Last Name:MAHLER
Suffix:
Gender:F
Credentials:LCSW,LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 GYPSY RD
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-9602
Mailing Address - Country:US
Mailing Address - Phone:315-560-2802
Mailing Address - Fax:
Practice Address - Street 1:4316 GYPSY RD
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-9602
Practice Address - Country:US
Practice Address - Phone:315-560-2802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070634-1104100000X
DEQ1-00011081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker