Provider Demographics
NPI:1619987773
Name:MCCONNELL, MELINDA ANN (MPT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BUD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:WV
Mailing Address - Zip Code:24983
Mailing Address - Country:US
Mailing Address - Phone:304-772-5639
Mailing Address - Fax:304-772-4639
Practice Address - Street 1:76 BUD RIDGE RD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983
Practice Address - Country:US
Practice Address - Phone:304-772-5639
Practice Address - Fax:304-772-4639
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001473OtherSTATE LICENSE
WV7303140000Medicaid
4126672Medicare ID - Type Unspecified