Healthcare Provider Details

I. General information

NPI: 1225430960
Provider Name (Legal Business Name): MAURYA MELLODY CARR MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MORGAN HWY
SCRANTON PA
18508-2641
US

IV. Provider business mailing address

5 MORGAN HWY SUITE 4
SCRANTON PA
18508-2641
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-3788
  • Fax:
Mailing address:
  • Phone: 570-344-3788
  • Fax: 570-969-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011771L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1225430960
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerUNITED HEALTH CARE
# 2
Identifier5242927
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA PPO
# 3
Identifier0425475
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HMO
# 4
Identifier003115168
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BS
# 5
Identifier833603
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerFPH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: