Provider Demographics
NPI:1093776627
Name:GUSTIS, MELISSA E (MPT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:E
Last Name:GUSTIS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CARPENTER CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1636
Mailing Address - Country:US
Mailing Address - Phone:630-248-5422
Mailing Address - Fax:630-724-0654
Practice Address - Street 1:2800 CARPENTER CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1636
Practice Address - Country:US
Practice Address - Phone:630-248-5422
Practice Address - Fax:630-724-0654
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist