Healthcare Provider Details

I. General information

NPI: 1457320038
Provider Name (Legal Business Name): MELINDA MARIE GILLIS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 VILLAGE CENTER DR STE 220
NORTH OAKS MN
55127-3014
US

IV. Provider business mailing address

5982 HIGHVIEW PL
SHOREVIEW MN
55126-8484
US

V. Phone/Fax

Practice location:
  • Phone: 651-482-8486
  • Fax:
Mailing address:
  • Phone: 651-484-1535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5406
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: