Provider Demographics
NPI:1629360391
Name:DYSHAW, MELISSA JEAN (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:DYSHAW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13770 44TH ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1262
Mailing Address - Country:US
Mailing Address - Phone:651-895-5364
Mailing Address - Fax:
Practice Address - Street 1:1127 W 8TH ST
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1467
Practice Address - Country:US
Practice Address - Phone:171-524-6685
Practice Address - Fax:171-524-6763
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11659024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist