Provider Demographics
NPI:1497419873
Name:BONGARD, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BONGARD
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 1:215 RADIO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-5817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 RADIO DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5817
Practice Address - Country:US
Practice Address - Phone:612-596-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MN6991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist