Provider Demographics
NPI:1932355658
Name:MILLER, MELISSA (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2932
Mailing Address - Country:US
Mailing Address - Phone:309-692-8670
Mailing Address - Fax:
Practice Address - Street 1:6501 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2932
Practice Address - Country:US
Practice Address - Phone:309-692-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070.018547OtherPT LICENSE
AZ5182OtherPT LICENSE