Provider Demographics
NPI:1275545964
Name:WALLACE, MELISSA A (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MRAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:23825 COMMERCE PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5837
Mailing Address - Country:US
Mailing Address - Phone:216-292-6363
Mailing Address - Fax:216-292-6306
Practice Address - Street 1:1502 TRAVELERS PT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-4046
Practice Address - Country:US
Practice Address - Phone:440-934-8184
Practice Address - Fax:440-934-8186
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-8782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist