Provider Demographics
NPI:1083624712
Name:BROCKMAN, MELISSA A (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:BAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1510 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1948
Mailing Address - Country:US
Mailing Address - Phone:920-487-3676
Mailing Address - Fax:
Practice Address - Street 1:1510 FREMONT ST
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-1948
Practice Address - Country:US
Practice Address - Phone:920-487-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5171024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5171024OtherLICENSE