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General NPI Number Information
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NPI Number | 1629360391
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Entity Type | Individual
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Provider Name | MELISSA JEAN DYSHAW D.P.T.
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Gender | Female
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Dates
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Enumeration Date | 05/12/2011
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Last Update Date | 12/04/2013
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Provider Practice Location Address
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Address Line | 1127 W 8TH ST
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City | NEW RICHMOND
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State | WI
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Zip | 54017-1467
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Country | US
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Telephone | 171-524-6685
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Fax | 171-524-6763
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Provider Business Mailing Address
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Address Line | 13770 44TH ST N
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City | STILLWATER
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State | MN
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Zip | 55082-1262
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Country | US
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Telephone | 651-895-5364
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11659024
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License Number State | WI
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