Provider Demographics
NPI:1962641118
Name:LICUPA, MELISSA JUNE N (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA JUNE
Middle Name:N
Last Name:LICUPA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 KUDER LANE
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582
Mailing Address - Country:US
Mailing Address - Phone:952-594-2262
Mailing Address - Fax:
Practice Address - Street 1:1106 KUDER LN
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-6421
Practice Address - Country:US
Practice Address - Phone:952-594-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009769A171W00000X
MD21483171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor