Provider Demographics
NPI:1477576338
Name:GLASS, MELISSA KEHAULANI INOUYE (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KEHAULANI INOUYE
Last Name:GLASS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:KEHAULANI
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2322 POWELL STREET
Mailing Address - Street 2:EMERYVILLE SPORTS PHYSICAL THERAPY
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608
Mailing Address - Country:US
Mailing Address - Phone:510-653-5151
Mailing Address - Fax:510-601-1358
Practice Address - Street 1:2322 POWELL STREET
Practice Address - Street 2:EMERYVILLE SPORTS PHYSICAL THERAPY
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1963
Practice Address - Country:US
Practice Address - Phone:510-653-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist