Healthcare Provider Details

I. General information

NPI: 1104937150
Provider Name (Legal Business Name): MELISA T CROSBY, PT P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 STATE ROAD 20
INTERLACHEN FL
32148-2430
US

IV. Provider business mailing address

885 STATE ROAD 20
INTERLACHEN FL
32148-2430
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: AMIE CARLE
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 386-684-9110