Provider Demographics
NPI:1700235124
Name:TICE, MELISSA (ATC , LAT)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:TICE
Suffix:
Gender:F
Credentials:ATC , LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N OLD ORCHARD LN
Mailing Address - Street 2:APT 231
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3649
Mailing Address - Country:US
Mailing Address - Phone:682-472-7907
Mailing Address - Fax:
Practice Address - Street 1:1098 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3518
Practice Address - Country:US
Practice Address - Phone:469-446-0381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT5006390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program