Provider Demographics
NPI:1790940401
Name:KEANE, MELISSA ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KEANE
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 1:307 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-2921
Mailing Address - Country:US
Mailing Address - Phone:865-983-0261
Mailing Address - Fax:
Practice Address - Street 1:307 N 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-2921
Practice Address - Country:US
Practice Address - Phone:865-983-0261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2431225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant