Provider Demographics
NPI:1265665236
Name:BRODT, MELISSA (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:BRODT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5908
Mailing Address - Country:US
Mailing Address - Phone:315-404-1236
Mailing Address - Fax:315-337-0991
Practice Address - Street 1:8200 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1027
Practice Address - Country:US
Practice Address - Phone:315-738-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031694-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist