Provider Demographics
NPI:1548380199
Name:MELTON, ED (LISW)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:
Last Name:MELTON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2526
Mailing Address - Country:US
Mailing Address - Phone:843-317-4089
Mailing Address - Fax:843-317-4096
Practice Address - Street 1:217 E CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4305
Practice Address - Country:US
Practice Address - Phone:843-332-4141
Practice Address - Fax:843-383-4625
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC376241Medicaid