Provider Demographics
NPI:1912627035
Name:SHUCK, MELISSA AMIT (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:AMIT
Last Name:SHUCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 GROSVENOR RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2628
Mailing Address - Country:US
Mailing Address - Phone:818-324-5632
Mailing Address - Fax:
Practice Address - Street 1:3545 GROSVENOR RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2628
Practice Address - Country:US
Practice Address - Phone:818-324-5632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.026026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist