Provider Demographics
NPI:1124182191
Name:MELWORM, BRETT W (MPT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:W
Last Name:MELWORM
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SKYVIEW GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NJ
Mailing Address - Zip Code:08833-3208
Mailing Address - Country:US
Mailing Address - Phone:908-687-1830
Mailing Address - Fax:
Practice Address - Street 1:47 MAPLE ST
Practice Address - Street 2:STE 108
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2571
Practice Address - Country:US
Practice Address - Phone:908-598-9009
Practice Address - Fax:908-598-9492
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00521000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ025247M47Medicare ID - Type Unspecified