Provider Demographics
NPI:1740650704
Name:DETULLIO, MELISSA (DC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DETULLIO
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 1:230 BLUE HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-6659
Mailing Address - Country:US
Mailing Address - Phone:845-518-6304
Mailing Address - Fax:
Practice Address - Street 1:230 BLUE HILL RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-6659
Practice Address - Country:US
Practice Address - Phone:845-518-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor