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General NPI Number Information
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NPI Number | 1760280481
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Entity Type | Individual
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Provider Name | TYLER EMERSON MELLECKER PTA
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Gender | Male
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Dates
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Enumeration Date | 03/06/2025
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Last Update Date | 03/06/2025
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Provider Practice Location Address
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Address Line | 20973 CORKSCREW SHORES BLVD
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City | ESTERO
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State | FL
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Zip | 33928-9146
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Country | US
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Telephone | 630-687-0574
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Fax | 239-320-3231
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Provider Business Mailing Address
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Address Line | 20973 CORKSCREW SHORES BLVD
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City | ESTERO
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State | FL
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Zip | 33928-9146
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Country | US
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Telephone | 630-687-0574
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Fax | 239-320-3231
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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 | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 27302
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 27302
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License Number State | FL
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