Provider Demographics
NPI:1588234165
Name:EDGE, MELISSA (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:EDGE
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 1:2283 COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-9266
Mailing Address - Country:US
Mailing Address - Phone:608-732-2277
Mailing Address - Fax:
Practice Address - Street 1:2283 COUNTY ROAD Y
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-9266
Practice Address - Country:US
Practice Address - Phone:608-732-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2469-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant