MEDICARE: MELISSA LEANNE CUSSANS PTA

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

General Provider Information

NPI Number	:	1639810401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LEANNE CUSSANS PTA

Provider Business Mailing Address
First Line	:	4627 PASTURE LN
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1846
Country	:	US
Telephone Number	:	810-965-3201
Fax Number	:

Provider Business Practice Location Address
First Line	:	4627 PASTURE LN
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1846
Country	:	US
Telephone Number	:	810-965-3201
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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