Provider Demographics
NPI:1053779652
Name:SMITH, MELISA
Entity type:Individual
Prefix:MRS
First Name:MELISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3529
Mailing Address - Country:US
Mailing Address - Phone:419-999-2030
Mailing Address - Fax:
Practice Address - Street 1:1010 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-9347
Practice Address - Country:US
Practice Address - Phone:419-738-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist