Provider Demographics
NPI:1548591530
Name:MELLO, KAREN (PTA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MELLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8005
Mailing Address - Country:US
Mailing Address - Phone:803-494-2558
Mailing Address - Fax:
Practice Address - Street 1:2825 CARTER RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1712
Practice Address - Country:US
Practice Address - Phone:803-469-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
SC2258174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist