Provider Demographics
NPI:1972261139
Name:MELLOTT, JUSTIN DEREK
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DEREK
Last Name:MELLOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13808 JENNY LN NE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ORLEANS
Mailing Address - State:MD
Mailing Address - Zip Code:21766-1034
Mailing Address - Country:US
Mailing Address - Phone:301-697-4004
Mailing Address - Fax:
Practice Address - Street 1:23 FITNESS LN
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-7080
Practice Address - Country:US
Practice Address - Phone:304-258-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT002131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPT002131OtherPHYSICAL THERAPY