Provider Demographics
NPI:1932617503
Name:MELLARD, FAYE JEAN (LMT, NMT)
Entity type:Individual
Prefix:MISS
First Name:FAYE
Middle Name:JEAN
Last Name:MELLARD
Suffix:
Gender:F
Credentials:LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 PAPER MILL RD APT 4103
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5345
Mailing Address - Country:US
Mailing Address - Phone:404-645-1263
Mailing Address - Fax:
Practice Address - Street 1:237 SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5621
Practice Address - Country:US
Practice Address - Phone:404-731-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA175T00000X
GAMT004030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No175T00000XOther Service ProvidersPeer Specialist