Provider Demographics
NPI:1821491747
Name:AUSTIN, MELANIE (LMT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 W BRYN MAWR AVE
Mailing Address - Street 2:APT 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4602
Mailing Address - Country:US
Mailing Address - Phone:773-456-4662
Mailing Address - Fax:
Practice Address - Street 1:1062 W BRYN MAWR AVE
Practice Address - Street 2:APT 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4602
Practice Address - Country:US
Practice Address - Phone:773-456-4662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227008941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist