Provider Demographics
NPI:1598928293
Name:KALISVAART, MELISSA T (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:T
Last Name:KALISVAART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10587 DOUBLE R BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8966
Mailing Address - Country:US
Mailing Address - Phone:775-324-5371
Mailing Address - Fax:775-852-5373
Practice Address - Street 1:10587 DOUBLE R BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-8966
Practice Address - Country:US
Practice Address - Phone:775-324-5371
Practice Address - Fax:775-852-5373
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8166225100000X
NV3236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVENROLLEDMedicaid
MNENROLLEDMedicaid
MNP00992409OtherMEDICARE RAILROAD
IAENROLLEDMedicaid
MNENROLLEDMedicaid