Provider Demographics
NPI:1295834109
Name:MELLOH, THERESA ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ELLEN
Last Name:MELLOH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 CALHOUN ST
Mailing Address - Street 2:BUILDING 5
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2649
Mailing Address - Country:US
Mailing Address - Phone:803-807-2356
Mailing Address - Fax:
Practice Address - Street 1:1898 CALHOUN ST
Practice Address - Street 2:BUILDING 5
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2649
Practice Address - Country:US
Practice Address - Phone:803-233-9174
Practice Address - Fax:803-233-2814
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4411Medicare PIN
SCQ41492Medicare UPIN