Provider Demographics
NPI:1225158504
Name:ROGERS, MELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 HOLTON AVE # B
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1526
Mailing Address - Country:US
Mailing Address - Phone:850-865-7127
Mailing Address - Fax:
Practice Address - Street 1:1301 EGLIN PKWY # F
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1208
Practice Address - Country:US
Practice Address - Phone:850-865-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 18713225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist