Provider Demographics
NPI:1174568513
Name:MELKADZE, LIYA (MS PT)
Entity type:Individual
Prefix:MS
First Name:LIYA
Middle Name:
Last Name:MELKADZE
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SAINT GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1525
Mailing Address - Country:US
Mailing Address - Phone:718-667-8006
Mailing Address - Fax:
Practice Address - Street 1:221 CHESTNUT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-1297
Practice Address - Country:US
Practice Address - Phone:908-620-0808
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01182400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ099032U4XMedicare ID - Type Unspecified