Provider Demographics
NPI:1790227569
Name:WALDEN, MELISSA ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WALDEN
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 1:420 OLD WAITSBORO RD
Mailing Address - Street 2:
Mailing Address - City:BRONSTON
Mailing Address - State:KY
Mailing Address - Zip Code:42518-8561
Mailing Address - Country:US
Mailing Address - Phone:606-561-7652
Mailing Address - Fax:
Practice Address - Street 1:305 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-679-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA00418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant