Provider Demographics
NPI:1649557299
Name:MCKIERNAN, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCKIERNAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-1110
Mailing Address - Country:US
Mailing Address - Phone:914-231-5723
Mailing Address - Fax:
Practice Address - Street 1:30 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706-1110
Practice Address - Country:US
Practice Address - Phone:914-231-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010462-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist