Provider Demographics
NPI:1548391121
Name:PETTAVINO, MELISSA S (PT, MPT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:S
Last Name:PETTAVINO
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19105 SANDY LANE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433
Mailing Address - Country:US
Mailing Address - Phone:985-792-7700
Mailing Address - Fax:985-247-8220
Practice Address - Street 1:19105 SANDY LANE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-792-7700
Practice Address - Fax:985-247-8220
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04135225100000X
225X00000X, 235Z00000X, 225100000X
LA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315795Medicaid