MEDICARE: MELLISSA BORST PT, DPT

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	17065-24	WI

General Provider Information

NPI Number	:	1578931937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELLISSA BORST PT, DPT

Provider Business Mailing Address
First Line	:	E2325 KING RD
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-1698
Country	:	US
Telephone Number	:	715-258-4124
Fax Number	:

Provider Business Practice Location Address
First Line	:	E2325 KING RD
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-8270
Country	:	US
Telephone Number	:	715-258-4124
Fax Number	:

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

Provider Enumeration Date	:	09/02/2015
Last Update Date	:	05/08/2026

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