Provider Demographics
NPI:1821374893
Name:SEGRAVES, MELINDA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:MICHELLE
Last Name:SEGRAVES
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 1:850 W IRONWOOD DR
Mailing Address - Street 2:302
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:509-868-8699
Mailing Address - Fax:208-664-5228
Practice Address - Street 1:850 W IRONWOOD DR
Practice Address - Street 2:302
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:509-868-8699
Practice Address - Fax:208-664-5228
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60245136225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist