Provider Demographics
NPI:1780383836
Name:STREETER, MELISSA (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:STREETER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 OSWEGATCHIE TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:STAR LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:13690-3143
Mailing Address - Country:US
Mailing Address - Phone:315-848-3351
Mailing Address - Fax:315-848-2440
Practice Address - Street 1:1014 OSWEGATCHIE TRAIL RD
Practice Address - Street 2:
Practice Address - City:STAR LAKE
Practice Address - State:NY
Practice Address - Zip Code:13690-3143
Practice Address - Country:US
Practice Address - Phone:315-848-3351
Practice Address - Fax:315-848-2440
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004074-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant