Provider Demographics
NPI:1598168197
Name:SMITH, MELINDA ELISE (LMT , MMP)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ELISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT , MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 FOXGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-2029
Mailing Address - Country:US
Mailing Address - Phone:260-246-9963
Mailing Address - Fax:
Practice Address - Street 1:5812 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3840
Practice Address - Country:US
Practice Address - Phone:260-969-7977
Practice Address - Fax:260-969-6590
Is Sole Proprietor?:No
Enumeration Date:2014-09-27
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT209000676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT209000676OtherMASSAGE THERAPY LICENSE NUMBER