Provider Demographics
NPI:1609814953
Name:BRACEWELL, MELANIE SUE (MSPT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:SUE
Last Name:BRACEWELL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:SUE
Other - Last Name:EL BACHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:100 LINDSEY LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6850
Mailing Address - Country:US
Mailing Address - Phone:912-729-1333
Mailing Address - Fax:
Practice Address - Street 1:100 LINDSEY LN
Practice Address - Street 2:SUITE A
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6850
Practice Address - Country:US
Practice Address - Phone:912-729-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA274053687AMedicaid
GA214563OtherBCBS GA
GA274053687B,C,DMedicaid
GA274053687AMedicaid
GA511I650258Medicare PIN