Healthcare Provider Details

I. General information

NPI: 1871922112
Provider Name (Legal Business Name): MELISSA DERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 S LAKE DR
LEXINGTON SC
29073-3720
US

IV. Provider business mailing address

1068 S LAKE DR
LEXINGTON SC
29073-3720
US

V. Phone/Fax

Practice location:
  • Phone: 803-726-9425
  • Fax: 803-726-9403
Mailing address:
  • Phone: 803-726-9425
  • Fax: 803-726-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: