Provider Demographics
NPI:1851789846
Name:KUTAC, MELISSA JEAN (LPTA)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:JEAN
Last Name:KUTAC
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W FAIRWINDS ST
Mailing Address - Street 2:
Mailing Address - City:HALLETTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77964-3531
Mailing Address - Country:US
Mailing Address - Phone:361-798-4885
Mailing Address - Fax:
Practice Address - Street 1:825 W FAIRWINDS ST
Practice Address - Street 2:
Practice Address - City:HALLETTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77964-3531
Practice Address - Country:US
Practice Address - Phone:361-798-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2033512225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant