Provider Demographics
NPI:1871692301
Name:HALDT, M'LISSA S (R P T)
Entity type:Individual
Prefix:
First Name:M'LISSA
Middle Name:S
Last Name:HALDT
Suffix:
Gender:F
Credentials:R P T
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 563
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-0563
Mailing Address - Country:US
Mailing Address - Phone:812-443-6144
Mailing Address - Fax:812-443-5506
Practice Address - Street 1:117 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2622
Practice Address - Country:US
Practice Address - Phone:812-443-6144
Practice Address - Fax:812-443-5506
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000255598OtherBCBS PIN
IN226280AMedicare PIN