Healthcare Provider Details

I. General information

NPI: 1104854447
Provider Name (Legal Business Name): ELIZABETH MELIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH PETERSON PT

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 08/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6233 DURAND AVE STE C
MOUNT PLEASANT WI
53406-4961
US

IV. Provider business mailing address

6233 DURAND AVE STE C
MOUNT PLEASANT WI
53406-4961
US

V. Phone/Fax

Practice location:
  • Phone: 262-456-2384
  • Fax: 262-456-2387
Mailing address:
  • Phone: 262-456-2384
  • Fax: 262-456-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004787
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11418-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: