Provider Demographics
NPI:1548392806
Name:MCCLENDON, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCCLENDON
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 1:554 90TH ST SW
Mailing Address - Street 2:EDWARD GONZALES ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7710
Mailing Address - Country:US
Mailing Address - Phone:505-831-6214
Mailing Address - Fax:
Practice Address - Street 1:554 90TH ST SW
Practice Address - Street 2:EDWARD GONZALES ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-7710
Practice Address - Country:US
Practice Address - Phone:505-831-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2583225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG 5011Medicaid