MEDICARE: MELISSA SHANNON QUILTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1487132239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA SHANNON QUILTY

Provider Business Mailing Address
First Line	:	3574 US 1 S STE 102
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-6467
Country	:	US
Telephone Number	:	904-217-7161
Fax Number	:	904-217-4075

Provider Business Practice Location Address
First Line	:	3574 US 1 S STE 102
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-6467
Country	:	US
Telephone Number	:	904-217-7161
Fax Number	:	904-217-4075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	08/03/2018

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