Provider Demographics
NPI:1356775233
Name:MEHALIC, ELLEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MEHALIC
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KRASNIAK
Other - Middle Name:
Other - Last Name:KRASNIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:4533 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3436
Mailing Address - Country:US
Mailing Address - Phone:540-772-8022
Mailing Address - Fax:540-772-0294
Practice Address - Street 1:3960 VALLEY GATEWAY BLVD STE A3
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-6859
Practice Address - Country:US
Practice Address - Phone:540-772-8022
Practice Address - Fax:540-772-0294
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62036789225100000X
VA2305208287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist