Provider Demographics
NPI:1407584865
Name:LOCKWOOD, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 MARSH DEER PL
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-6204
Mailing Address - Country:US
Mailing Address - Phone:843-550-0252
Mailing Address - Fax:
Practice Address - Street 1:171 MARSH DEER PL
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6204
Practice Address - Country:US
Practice Address - Phone:843-550-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC252Y00000XMedicaid