Provider Demographics
NPI:1295015337
Name:WATTERS, MELISSA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:WATTERS
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 1:4236 W 700 S
Mailing Address - Street 2:
Mailing Address - City:PONETO
Mailing Address - State:IN
Mailing Address - Zip Code:46781-9752
Mailing Address - Country:US
Mailing Address - Phone:260-820-1602
Mailing Address - Fax:
Practice Address - Street 1:1800 N WABASH RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1300
Practice Address - Country:US
Practice Address - Phone:765-251-1003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004245A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant