Provider Demographics
NPI:1134608425
Name:MELLOM, THERESA (DC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MELLOM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-5383
Mailing Address - Country:US
Mailing Address - Phone:262-334-8188
Mailing Address - Fax:262-334-8166
Practice Address - Street 1:820 E PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5383
Practice Address - Country:US
Practice Address - Phone:262-334-8188
Practice Address - Fax:262-334-8166
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5290-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor