Provider Demographics
NPI:1134179617
Name:HAVERDILL, MELISSA A (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:HAVERDILL
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 1:2132 CASE PARKWAY N SUITE A
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087
Mailing Address - Country:US
Mailing Address - Phone:330-963-2920
Mailing Address - Fax:330-963-2921
Practice Address - Street 1:6950 SOUTH EDGERTON
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141
Practice Address - Country:US
Practice Address - Phone:440-746-1730
Practice Address - Fax:440-746-1732
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2705497Medicaid
OH31-1556919OtherTAX ID