Healthcare Provider Details

I. General information

NPI: 1104937135
Provider Name (Legal Business Name): MELISA T CROSBY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505A ATLANTIC AVE
INTERLACHEN FL
32148-5433
US

IV. Provider business mailing address

505A ATLANTIC AVE
INTERLACHEN FL
32148-5433
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-9110
  • Fax: 386-684-9255
Mailing address:
  • Phone: 386-684-9110
  • Fax: 386-684-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 8102
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: