Provider Demographics
NPI:1356848238
Name:ANDERSEN, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:PASSANANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2580 LIN DO CT
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1832
Mailing Address - Country:US
Mailing Address - Phone:803-905-4427
Mailing Address - Fax:803-905-4431
Practice Address - Street 1:1123 QUEENSBOROUGH BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3682
Practice Address - Country:US
Practice Address - Phone:843-352-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17-46196106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician