MEDICARE: MELISSA MASSINGALE

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	225200000X	Physical Therapy Assistant	PTA004162	GA

General Provider Information

NPI Number	:	1376156117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA MASSINGALE

Provider Business Mailing Address
First Line	:	2011 SHADOW BLUFF CT NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-2564
Country	:	US
Telephone Number	:	678-516-1368
Fax Number	:

Provider Business Practice Location Address
First Line	:	965 PIEDMONT RD NE STE 200
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-5493
Country	:	US
Telephone Number	:	770-575-2212
Fax Number	:

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

Provider Enumeration Date	:	08/30/2020
Last Update Date	:	08/30/2020

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Directions to “ MELISSA MASSINGALE ” Practice Location

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