Provider Demographics
NPI:1720188642
Name:PUCAK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PUCAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 CUSTER ORANGEVILLE RD NE
Mailing Address - Street 2:
Mailing Address - City:BURGHILL
Mailing Address - State:OH
Mailing Address - Zip Code:44404-9774
Mailing Address - Country:US
Mailing Address - Phone:304-593-1064
Mailing Address - Fax:
Practice Address - Street 1:885 HOWLAND WILSON RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2115
Practice Address - Country:US
Practice Address - Phone:330-856-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002012225100000X
OH9255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist