Provider Demographics
NPI:1770069205
Name:TYSOWSKY, MELANA T
Entity type:Individual
Prefix:
First Name:MELANA
Middle Name:T
Last Name:TYSOWSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2765
Mailing Address - Country:US
Mailing Address - Phone:513-803-8158
Mailing Address - Fax:
Practice Address - Street 1:6555 CLYO RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2765
Practice Address - Country:US
Practice Address - Phone:513-803-8158
Practice Address - Fax:513-803-1111
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2187155Medicaid
OHAB7360731OtherMEDICARE PIN