Provider Demographics
NPI:1689981870
Name:MILLER, MELINA LEA (PTA)
Entity Type:Individual
Prefix:
First Name:MELINA
Middle Name:LEA
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MELINA
Other - Middle Name:LEA
Other - Last Name:FRESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 70940
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0034
Mailing Address - Country:US
Mailing Address - Phone:609-306-9429
Mailing Address - Fax:
Practice Address - Street 1:101 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8275
Practice Address - Country:US
Practice Address - Phone:843-903-8958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2474225200000X
NJ40QB00245900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant