Provider Demographics
NPI:1689841447
Name:BURWELL, MELINDA D (PT)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:D
Last Name:BURWELL
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 1:2216 STATE HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-4408
Mailing Address - Country:US
Mailing Address - Phone:315-854-6889
Mailing Address - Fax:
Practice Address - Street 1:2216 STATE HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-4408
Practice Address - Country:US
Practice Address - Phone:315-854-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028724-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NY01995615Medicaid