Provider Demographics
NPI:1669520276
Name:MECHTENBERG, MELISSA ANN (DC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MECHTENBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MECHTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:120 5TH AVE S
Mailing Address - Street 2:PO BOX 147
Mailing Address - City:STRUM
Mailing Address - State:WI
Mailing Address - Zip Code:54770-7931
Mailing Address - Country:US
Mailing Address - Phone:715-695-2946
Mailing Address - Fax:715-695-3169
Practice Address - Street 1:120 5TH AVE S
Practice Address - Street 2:
Practice Address - City:STRUM
Practice Address - State:WI
Practice Address - Zip Code:54770-7931
Practice Address - Country:US
Practice Address - Phone:715-695-2946
Practice Address - Fax:715-695-3169
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3640-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38922800Medicaid
WI38922800Medicaid
WI000135709Medicare PIN