Provider Demographics
NPI:1760098149
Name:ADEMA, MELINDA ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:ADEMA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2156 VALLEY FORGE ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5952
Mailing Address - Country:US
Mailing Address - Phone:616-450-6891
Mailing Address - Fax:
Practice Address - Street 1:4450 CASCADE RD SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3633
Practice Address - Country:US
Practice Address - Phone:616-965-9562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000219225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant