=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922330356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA MABLE LAYE DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2010
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1366 US HIGHWAY 82 W
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31763-5810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-883-4009
-----------------------------------------------------
Fax | 229-336-1151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 E BROAD ST
-----------------------------------------------------
City | CAMILLA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31730-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-336-1115
-----------------------------------------------------
Fax | 229-336-1151
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 009865
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------