Provider Demographics
NPI:1851593172
Name:PETERS, MELINDA J (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:J
Last Name:PETERS
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 1:301 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2358
Mailing Address - Country:US
Mailing Address - Phone:626-815-5966
Mailing Address - Fax:
Practice Address - Street 1:9227 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5420
Practice Address - Country:US
Practice Address - Phone:800-642-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT2087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant