Provider Demographics
NPI:1609102730
Name:MAITLAND, MELINDA K (MED)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:K
Last Name:MAITLAND
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 OLD CHARTWELL DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8511
Mailing Address - Country:US
Mailing Address - Phone:717-357-1869
Mailing Address - Fax:866-358-3496
Practice Address - Street 1:125 OLD CHARTWELL DR
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8511
Practice Address - Country:US
Practice Address - Phone:717-357-1869
Practice Address - Fax:866-358-3496
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA222Q00000X252Y00000X
PA05044769174400000X
GA1356881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency