Provider Demographics
NPI:1275648115
Name:STACK, MELISSA DIANE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DIANE
Last Name:STACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14220 NORTHBROOK
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232
Mailing Address - Country:US
Mailing Address - Phone:210-822-8807
Mailing Address - Fax:210-822-8863
Practice Address - Street 1:8800 VILLAGE DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-654-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10364652251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2322Medicare PIN