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General NPI Number Information
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NPI Number | 1811421837
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Entity Type | Individual
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Provider Name | MELISSA ERICSON DAT, LAT
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Gender | Female
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Dates
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Enumeration Date | 04/17/2017
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 3365 S 103RD ST
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City | MILWAUKEE
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State | WI
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Zip | 53227-4161
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Country | US
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Telephone | 262-604-7515
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Fax |
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Provider Business Mailing Address
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Address Line | 1711 S EAST LN
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City | NEW BERLIN
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State | WI
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Zip | 53146-1502
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Country | US
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Telephone |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36002463A
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License Number State | IN
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