Provider Demographics
NPI:1467848572
Name:WILSON, MELISSA ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 NW PARK TER
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1264
Mailing Address - Country:US
Mailing Address - Phone:541-974-9744
Mailing Address - Fax:
Practice Address - Street 1:7120 CORBIN AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3618
Practice Address - Country:US
Practice Address - Phone:818-881-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT10727225200000X
OR08934225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant