Provider Demographics
NPI:1639661168
Name:SANTORO, MELISSA (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SANTORO
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 1:2726 WILDER RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33566-7574
Mailing Address - Country:US
Mailing Address - Phone:813-516-6446
Mailing Address - Fax:
Practice Address - Street 1:1826 N CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5905
Practice Address - Country:US
Practice Address - Phone:813-876-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25392225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant