Provider Demographics
NPI:1992213847
Name:MOW, MELODIE
Entity Type:Individual
Prefix:
First Name:MELODIE
Middle Name:
Last Name:MOW
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 1:424 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3740
Practice Address - Country:US
Practice Address - Phone:844-543-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty