Provider Demographics
NPI:1497974109
Name:ANDERSON, MELISSA DYAN (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DYAN
Last Name:ANDERSON
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 1:703 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-1717
Mailing Address - Country:US
Mailing Address - Phone:479-936-7647
Mailing Address - Fax:
Practice Address - Street 1:500 TIGER BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-2011
Practice Address - Country:US
Practice Address - Phone:479-254-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT28262251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics