Provider Demographics
NPI:1790198240
Name:CAPASSO, MELISSA MIRANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MIRANDA
Last Name:CAPASSO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MIRANDA
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 NEW BRIDGE ST STE 10A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4700
Mailing Address - Country:US
Mailing Address - Phone:910-347-2212
Mailing Address - Fax:910-338-5013
Practice Address - Street 1:410 NEW BRIDGE ST STE 10A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-347-2212
Practice Address - Fax:910-338-5013
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18468225100000X
SC7393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1790198240Medicaid