Provider Demographics
NPI:1811221500
Name:THEETGE, MELISSA ANN (LCMT)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:THEETGE
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 FLAT RIVER RD
Mailing Address - Street 2:BOX #9
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-8959
Mailing Address - Country:US
Mailing Address - Phone:401-385-9485
Mailing Address - Fax:401-385-9485
Practice Address - Street 1:2260 FLAT RIVER RD
Practice Address - Street 2:BOX #9
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-8959
Practice Address - Country:US
Practice Address - Phone:401-385-9485
Practice Address - Fax:401-385-9485
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT00601172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist