Provider Demographics
NPI:1215002118
Name:SIMON, MELINDA (MSPT, AT, C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:MSPT, AT, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-954-0950
Mailing Address - Fax:616-954-1728
Practice Address - Street 1:7751 BYRON CENTER AVE SW
Practice Address - Street 2:SUITE B
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8001
Practice Address - Country:US
Practice Address - Phone:616-878-1878
Practice Address - Fax:616-878-1816
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236697Medicare ID - Type Unspecified