Provider Demographics
NPI:1497052047
Name:PAWLAK, MELISSA (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PAWLAK
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 1:85 NE LOOP 410 STE 612
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5866
Mailing Address - Country:US
Mailing Address - Phone:210-494-2343
Mailing Address - Fax:
Practice Address - Street 1:85 NE LOOP 410 STE 612
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5866
Practice Address - Country:US
Practice Address - Phone:210-494-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2079790225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2079790OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINERS