Provider Demographics
NPI:1487132239
Name:QUILTY, MELISSA SHANNON
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SHANNON
Last Name:QUILTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3574 US 1 S STE 102
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6467
Mailing Address - Country:US
Mailing Address - Phone:904-217-7161
Mailing Address - Fax:904-217-4075
Practice Address - Street 1:3574 US 1 S STE 102
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6467
Practice Address - Country:US
Practice Address - Phone:904-217-7161
Practice Address - Fax:904-217-4075
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty