Provider Demographics
NPI:1801103957
Name:MAUL, MELINDA A (LPTA)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:A
Last Name:MAUL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CONGERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61729-0074
Mailing Address - Country:US
Mailing Address - Phone:309-258-7701
Mailing Address - Fax:
Practice Address - Street 1:208 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CONGERVILLE
Practice Address - State:IL
Practice Address - Zip Code:61729-0074
Practice Address - Country:US
Practice Address - Phone:309-258-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9110911000Medicare Oscar/Certification
IL9110911000Medicare PIN
IL9110911000Medicare UPIN
IL9110911000Medicare NSC