Provider Demographics
NPI:1598885063
Name:BRAGG, MELISSA SUE (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:BRAGG
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:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:GHENT
Mailing Address - State:WV
Mailing Address - Zip Code:25843-0143
Mailing Address - Country:US
Mailing Address - Phone:304-787-9757
Mailing Address - Fax:
Practice Address - Street 1:1631 RITTER DR
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9264
Practice Address - Country:US
Practice Address - Phone:304-763-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000478225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant