Provider Demographics
NPI:1194181750
Name:WILLIAMS, MELISSA SUZANNE (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUZANNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:SUZANNE
Other - Last Name:EZELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-759-7451
Mailing Address - Fax:812-759-7482
Practice Address - Street 1:702 BARRETT BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4931
Practice Address - Country:US
Practice Address - Phone:270-631-4100
Practice Address - Fax:270-631-4101
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02954225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant