Provider Demographics
NPI:1871600577
Name:EVANS, MELISSA MORANTE (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MORANTE
Last Name:EVANS
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:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-1300
Mailing Address - Country:US
Mailing Address - Phone:210-695-2682
Mailing Address - Fax:210-337-7966
Practice Address - Street 1:3875 E SOUTHCROSS BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3521
Practice Address - Country:US
Practice Address - Phone:210-337-7953
Practice Address - Fax:210-337-7966
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1139590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX819T69OtherBLUE CROSS BLUE SHIELD
TX211725101Medicaid
TX8L15163Medicare PIN