Provider Demographics
NPI:1952554099
Name:DUCKETT, MELISSA LEE (PTA)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LEE
Last Name:DUCKETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:LEE
Other - Last Name:MEILACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5540 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5574
Mailing Address - Country:US
Mailing Address - Phone:708-422-1311
Mailing Address - Fax:708-422-1812
Practice Address - Street 1:5540 W 111TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5574
Practice Address - Country:US
Practice Address - Phone:708-422-1311
Practice Address - Fax:708-422-1812
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004652225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant