Provider Demographics
NPI:1760043921
Name:WILSON, MELISSA M (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:WILSON
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 734839
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4839
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:
Practice Address - Street 1:610 E BRANNON RD STE 200
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6046
Practice Address - Country:US
Practice Address - Phone:859-260-5555
Practice Address - Fax:859-260-5556
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist