Provider Demographics
NPI:1578679833
Name:BENTLEY, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1600 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1408
Mailing Address - Country:US
Mailing Address - Phone:478-743-3000
Mailing Address - Fax:478-741-9657
Practice Address - Street 1:1600 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1408
Practice Address - Country:US
Practice Address - Phone:478-743-3000
Practice Address - Fax:478-741-9657
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0008837225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00370125OtherMEDICARE RAILROAD PTAN
65BBDSSMedicare PIN