MEDICARE: MELANIE LEITE-CARROLL PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4721	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HP31029	OTHER	MN	HEALTHPARTNERS
2	35T43LE	OTHER	MN	BC/BS
3	64-00146	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1154317915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANIE LEITE-CARROLL PT

Provider Business Mailing Address
First Line	:	6726 CANTERBURY LN
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55346-2843
Country	:	US
Telephone Number	:	952-203-4729
Fax Number	:

Provider Business Practice Location Address
First Line	:	6726 CANTERBURY LN
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55346-2843
Country	:	US
Telephone Number	:	952-203-4729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	07/08/2007

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