Provider Demographics
NPI:1942951330
Name:DETTMER, MELINDA J (LMT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:J
Last Name:DETTMER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:J
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:6807 AUTUMN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6304
Mailing Address - Country:US
Mailing Address - Phone:410-984-8056
Mailing Address - Fax:
Practice Address - Street 1:6300 GEORGETOWN BLVD STE 137-138
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6481
Practice Address - Country:US
Practice Address - Phone:443-531-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM02011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist