Provider Demographics
NPI:1013418771
Name:RUDDY, MELANIE SUE (PTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:SUE
Last Name:RUDDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:NEW LOTHROP
Mailing Address - State:MI
Mailing Address - Zip Code:48460-0446
Mailing Address - Country:US
Mailing Address - Phone:810-241-6843
Mailing Address - Fax:
Practice Address - Street 1:4180 TITTABAWASSEE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9413
Practice Address - Country:US
Practice Address - Phone:989-607-1500
Practice Address - Fax:989-401-2048
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000898225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502000898Medicaid