Provider Demographics
NPI:1609033851
Name:WOLF, MELISSA B (RPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:WOLF
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2197
Mailing Address - Country:US
Mailing Address - Phone:203-735-8336
Mailing Address - Fax:203-735-3704
Practice Address - Street 1:917 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4679
Practice Address - Country:US
Practice Address - Phone:203-735-8336
Practice Address - Fax:203-735-3704
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007541225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics