Provider Demographics
NPI:1063208510
Name:MELLO, KATLIN
Entity type:Individual
Prefix:
First Name:KATLIN
Middle Name:
Last Name:MELLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 FOXPORT DR
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7544
Mailing Address - Country:US
Mailing Address - Phone:272-209-2678
Mailing Address - Fax:
Practice Address - Street 1:1720 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8871
Practice Address - Country:US
Practice Address - Phone:803-816-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist