Provider Demographics
NPI:1760867295
Name:WILSON, MELISSA LOUISE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LOUISE
Last Name:WILSON
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 1:2052 LEBANON RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-2143
Mailing Address - Country:US
Mailing Address - Phone:765-362-4151
Mailing Address - Fax:765-362-4161
Practice Address - Street 1:2052 LEBANON RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2143
Practice Address - Country:US
Practice Address - Phone:765-362-4151
Practice Address - Fax:765-362-4161
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004260A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant