Provider Demographics
NPI:1932153624
Name:KOZELICHKI, MELANIE RUTH
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:RUTH
Last Name:KOZELICHKI
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-0337
Mailing Address - Country:US
Mailing Address - Phone:423-942-3009
Mailing Address - Fax:423-942-3099
Practice Address - Street 1:501A WESTFIELD PL
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-5144
Practice Address - Country:US
Practice Address - Phone:423-942-3009
Practice Address - Fax:423-942-3099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000002319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3110918OtherBLUECROSS BLUESHIELD OF T
TN3110918OtherBLUECROSS BLUESHIELD OF T
TN446558Medicare ID - Type Unspecified