Provider Demographics
NPI:1750708541
Name:MINNICK, MEGHAN ELISE (DPT)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ELISE
Last Name:MINNICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11617 STELLA BLUE DR
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-8494
Mailing Address - Country:US
Mailing Address - Phone:406-546-3355
Mailing Address - Fax:
Practice Address - Street 1:1410 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4758
Practice Address - Country:US
Practice Address - Phone:140-682-9960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-5947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist