Provider Demographics
NPI:1578280897
Name:MILLER, MELISSA JANE (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:MILLER
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 1:24063 CAMEO CT
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-5633
Mailing Address - Country:US
Mailing Address - Phone:574-215-0540
Mailing Address - Fax:
Practice Address - Street 1:420 S DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-2310
Practice Address - Country:US
Practice Address - Phone:260-463-2831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004326A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant