Provider Demographics
NPI:1154317915
Name:LEITE-CARROLL, MELANIE (PT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:LEITE-CARROLL
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 1:6726 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-2843
Mailing Address - Country:US
Mailing Address - Phone:952-203-4729
Mailing Address - Fax:
Practice Address - Street 1:6726 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346-2843
Practice Address - Country:US
Practice Address - Phone:952-203-4729
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP31029OtherHEALTHPARTNERS
MN35T43LEOtherBC/BS
MN64-00146OtherMEDICA