Provider Demographics
NPI:1376987461
Name:EDMONDSON, MELISSA D (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3914
Mailing Address - Country:US
Mailing Address - Phone:575-838-4690
Mailing Address - Fax:575-838-4689
Practice Address - Street 1:1204 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-838-4690
Practice Address - Fax:575-838-4689
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4287OtherNM STATE LICENSE