Provider Demographics
NPI:1104854447
Name:MELIS, ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:MELIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6233 DURAND AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4961
Mailing Address - Country:US
Mailing Address - Phone:262-456-2384
Mailing Address - Fax:262-456-2387
Practice Address - Street 1:6233 DURAND AVE STE C
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4961
Practice Address - Country:US
Practice Address - Phone:262-456-2384
Practice Address - Fax:262-456-2387
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004787225100000X
WI11418-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist