Provider Demographics
NPI:1134596539
Name:MALM, MELISSA (LMT, NCTMB)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:
Last Name:MALM
Suffix:
Gender:F
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 ALIDA ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2158
Mailing Address - Country:US
Mailing Address - Phone:415-595-0328
Mailing Address - Fax:
Practice Address - Street 1:180 ALIDA ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2158
Practice Address - Country:US
Practice Address - Phone:415-595-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17972225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist