Healthcare Provider Details

I. General information

NPI: 1114090495
Provider Name (Legal Business Name): MELISSA N MCCORMICK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7707 W DEER VALLEY RD SUITE 105
PEORIA AZ
85382-2101
US

IV. Provider business mailing address

12945 W CRITTENDEN LN
AVONDALE AZ
85392-6686
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-9100
  • Fax: 623-376-9100
Mailing address:
  • Phone: 623-376-9100
  • Fax: 623-376-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7367
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: