Provider Demographics
NPI:1275180523
Name:POPE-REEDY, MELISA M (PTA)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:M
Last Name:POPE-REEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310A SINNISSIPPI PARK RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-4127
Mailing Address - Country:US
Mailing Address - Phone:815-213-0691
Mailing Address - Fax:
Practice Address - Street 1:1006 N LOWDEN RD
Practice Address - Street 2:
Practice Address - City:MOUNT CARROLL
Practice Address - State:IL
Practice Address - Zip Code:61053-9476
Practice Address - Country:US
Practice Address - Phone:815-244-7715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004978225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant