Provider Demographics
NPI:1710070362
Name:MELISSA MERCOGLIANO, PT, PS
Entity Type:Organization
Organization Name:MELISSA MERCOGLIANO, PT, PS
Other - Org Name:CENTER FOR ORTHOPEDIC & LYMPHATIC PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:AUTHIER
Authorized Official - Last Name:MERCOGLIANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:360-874-0745
Mailing Address - Street 1:463 TREMONT STREET WEST
Mailing Address - Street 2:STE 100
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366
Mailing Address - Country:US
Mailing Address - Phone:360-874-0745
Mailing Address - Fax:360-874-0846
Practice Address - Street 1:463 TREMONT STREET WEST
Practice Address - Street 2:STE 100
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-874-0745
Practice Address - Fax:360-874-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA472217001OtherALLIANCE
WA137035OtherLABOR AND INDUSTRIES WA
5214359OtherAETNA
WA5414MEOtherREGENCE
WA8805657Medicare ID - Type Unspecified
WA6195600001Medicare NSC