Healthcare Provider Details

I. General information

NPI: 1588303606
Provider Name (Legal Business Name): MELONEE PEARL CROUSE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 E BROADWAY RD STE 116-6
TEMPE AZ
85282-1633
US

IV. Provider business mailing address

1845 E BROADWAY RD STE 116-6
TEMPE AZ
85282-1633
US

V. Phone/Fax

Practice location:
  • Phone: 480-770-6641
  • Fax:
Mailing address:
  • Phone: 480-770-6641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-09980
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMT-09980
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: