Provider Demographics
NPI:1306847959
Name:LAFOLLETTE, MELISSA ANN (PT MT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:LAFOLLETTE
Suffix:
Gender:F
Credentials:PT MT
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT MT
Mailing Address - Street 1:4701 CREEK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-8398
Mailing Address - Country:US
Mailing Address - Phone:513-733-9333
Mailing Address - Fax:513-588-2479
Practice Address - Street 1:4440 GLEN ESTE WITHAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1318
Practice Address - Country:US
Practice Address - Phone:513-943-3630
Practice Address - Fax:513-753-4308
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.013454225700000X
OHPT.009877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815452Medicaid
OH2693036Medicaid
OH0815452Medicaid
OHJ04097262Medicare ID - Type Unspecified
OH4097263Medicare PIN
OH2693036Medicaid