Provider Demographics
NPI:1750816070
Name:MCDERMOTT, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LIEPOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:771 N FREEDOM ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2470
Mailing Address - Country:US
Mailing Address - Phone:330-297-9020
Mailing Address - Fax:
Practice Address - Street 1:771 N FREEDOM ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2470
Practice Address - Country:US
Practice Address - Phone:330-297-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist