Provider Demographics
NPI:1124183496
Name:DEMELLO, ROSEMARY (PT)
Entity Type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:
Last Name:DEMELLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 PROVIDENCE RD S
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7434
Mailing Address - Country:US
Mailing Address - Phone:704-256-4281
Mailing Address - Fax:704-256-4282
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:509
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-256-4281
Practice Address - Fax:704-256-4282
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211760Medicaid