Provider Demographics
NPI:1962703579
Name:MERRITT, MELISSA KATE (LMT)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:KATE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BERKELEY RD
Mailing Address - Street 2:#2
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 BERKELEY RD
Practice Address - Street 2:#2
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002-1467
Practice Address - Country:US
Practice Address - Phone:404-920-8492
Practice Address - Fax:404-920-8641
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT0004156225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist