Provider Demographics
NPI:1437380839
Name:MELVILLE, JOEL BENNETT (PT)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:BENNETT
Last Name:MELVILLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8645
Mailing Address - Fax:781-744-5215
Practice Address - Street 1:16 HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-7929
Practice Address - Country:US
Practice Address - Phone:781-744-7060
Practice Address - Fax:781-744-7069
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110083104AMedicaid
MA001181903Medicare PIN