Healthcare Provider Details

I. General information

NPI: 1689790396
Provider Name (Legal Business Name): MELINDA J ANTONIK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 BAKER RIDGE RD
MORGANTOWN WV
26508
US

IV. Provider business mailing address

1423 PALACE DR
MORGANTOWN WV
26508-9185
US

V. Phone/Fax

Practice location:
  • Phone: 304-285-0692
  • Fax:
Mailing address:
  • Phone: 304-292-5452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number001288
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT008393L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: