Provider Demographics
NPI:1740560481
Name:TATE, MELISSA FANNING (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FANNING
Last Name:TATE
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:PO BOX 1536
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:LA
Mailing Address - Zip Code:70711-1536
Mailing Address - Country:US
Mailing Address - Phone:985-320-0264
Mailing Address - Fax:
Practice Address - Street 1:19089 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:LA
Practice Address - Zip Code:70711-3603
Practice Address - Country:US
Practice Address - Phone:225-209-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA064002251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics