Provider Demographics
NPI:1780151407
Name:MELQUIST, MORGAN
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:MELQUIST
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 1:816 S ADAMS ST APT B605
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:816 S ADAMS ST APT B605
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-3614
Practice Address - Country:US
Practice Address - Phone:716-720-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960056272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096005627OtherIDFPR STATE LICENSURE FOR ATHLETIC TRAINERS
00000000000OtherN/A
2000035346OtherATHLETIC TRAINING BOARD OF CERTIFICATION (BOC)