Healthcare Provider Details

I. General information

NPI: 1730846775
Provider Name (Legal Business Name): MELISSA R MALINE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E LIONS CLUB DR
ROLLA MO
65401-4356
US

IV. Provider business mailing address

110 CASTLEBERRY CIR
FORT LEONARD WOOD MO
65473-8038
US

V. Phone/Fax

Practice location:
  • Phone: 573-375-9032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2018033720
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: