Provider Demographics
NPI:1508167768
Name:ROEDER, MELISSA CLARE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CLARE
Last Name:ROEDER
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 1:7300 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-6525
Mailing Address - Country:US
Mailing Address - Phone:262-321-6000
Mailing Address - Fax:262-321-6010
Practice Address - Street 1:7300 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-6525
Practice Address - Country:US
Practice Address - Phone:262-321-6000
Practice Address - Fax:262-321-6010
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1658019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant