Provider Demographics
NPI:1912041740
Name:VICKERS, MELISSA LYN (PT)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:LYN
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11824 SOUTHWEST HWY
Mailing Address - Street 2:STE 230
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1055
Mailing Address - Country:US
Mailing Address - Phone:708-671-1175
Mailing Address - Fax:708-671-1176
Practice Address - Street 1:11824 SOUTHWEST HWY
Practice Address - Street 2:STE 230
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1055
Practice Address - Country:US
Practice Address - Phone:708-671-1175
Practice Address - Fax:708-671-1176
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700141652251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics