Provider Demographics
NPI:1043307333
Name:WADDELL, MELISSA MAE (PT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MAE
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 RARDEN RD
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1049
Mailing Address - Country:US
Mailing Address - Phone:937-587-9422
Mailing Address - Fax:937-587-9522
Practice Address - Street 1:118 RARDEN RD
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-1049
Practice Address - Country:US
Practice Address - Phone:937-587-9422
Practice Address - Fax:937-587-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT0057402081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31-1448551OtherTAX ID