Provider Demographics
NPI:1033249610
Name:MELTON, MAVIS JOY (PT)
Entity Type:Individual
Prefix:MRS
First Name:MAVIS
Middle Name:JOY
Last Name:MELTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 CHANDLER DR
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-2202
Mailing Address - Country:US
Mailing Address - Phone:715-939-1745
Mailing Address - Fax:715-939-1557
Practice Address - Street 1:1280 CHANDLER DR
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-2202
Practice Address - Country:US
Practice Address - Phone:715-939-1745
Practice Address - Fax:715-939-1557
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6410024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40364300Medicaid
WIP00452883Medicare PIN
WIP00452883Medicare UPIN
WI000680050Medicare PIN