Provider Demographics
NPI:1205065307
Name:MELLINGER, KEVIN JAMES (MSPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:MELLINGER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 ROUTE 130
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-2525
Mailing Address - Country:US
Mailing Address - Phone:856-461-8331
Mailing Address - Fax:856-461-9099
Practice Address - Street 1:2902 ROUTE 130
Practice Address - Street 2:
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-2525
Practice Address - Country:US
Practice Address - Phone:856-461-8331
Practice Address - Fax:856-461-9099
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01317000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist