Healthcare Provider Details

I. General information

NPI: 1114309341
Provider Name (Legal Business Name): JULIE MELLO PTA, ATC, CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 STONE VALLEY RD
DANVILLE CA
94526-1129
US

IV. Provider business mailing address

19 DONNA LN
DANVILLE CA
94526-1505
US

V. Phone/Fax

Practice location:
  • Phone: 925-785-8892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT 4199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: