Provider Demographics
NPI:1639603848
Name:VINCENT, MALENA (PTA)
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-5505
Mailing Address - Country:US
Mailing Address - Phone:406-892-3256
Mailing Address - Fax:406-892-0143
Practice Address - Street 1:400 VETERANS DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-5505
Practice Address - Country:US
Practice Address - Phone:406-892-3256
Practice Address - Fax:406-892-0143
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11235225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant