Provider Demographics
NPI:1356675805
Name:CANTRELL, MELISSA A (MPT)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:A
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7166
Mailing Address - Country:US
Mailing Address - Phone:309-779-2828
Mailing Address - Fax:309-779-2839
Practice Address - Street 1:4112 46TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7166
Practice Address - Country:US
Practice Address - Phone:309-779-2828
Practice Address - Fax:309-779-2839
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist