Provider Demographics
NPI:1568597599
Name:STUTZRIEM, MELISSA MARIE (MSPT, CSCS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:STUTZRIEM
Suffix:
Gender:F
Credentials:MSPT, CSCS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MAIRE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT, CSCS
Mailing Address - Street 1:2430 WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-0756
Mailing Address - Country:US
Mailing Address - Phone:715-212-1524
Mailing Address - Fax:
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-456-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1057424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist