Provider Demographics
NPI:1447483177
Name:ROTELLO, MARTA CAROLYN (MED)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:CAROLYN
Last Name:ROTELLO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2554
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-2554
Mailing Address - Country:US
Mailing Address - Phone:843-251-4208
Mailing Address - Fax:843-626-0189
Practice Address - Street 1:507C 31ST AVE. N.
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-2905
Practice Address - Country:US
Practice Address - Phone:843-251-4208
Practice Address - Fax:843-626-0189
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2272101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP9919Medicaid