Provider Demographics
NPI:1942595889
Name:SHOLOMICKY, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SHOLOMICKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-1544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 BIRCH ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:OR
Practice Address - Zip Code:97448-1524
Practice Address - Country:US
Practice Address - Phone:541-998-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0977225200000X
CT001096225200000X
OR09465225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant