Basic Information
| Provider Information | |||||||||
| NPI: | 1104837715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S JAMES ST | ||||||||
| Address2: | BOUTON PHYSICAL THERAPY | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153371436 | ||||||||
| FaxNumber: | 3153371437 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 S JAMES ST | ||||||||
| Address2: | BOUTON PHYSICAL THERAPY | ||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153371436 | ||||||||
| FaxNumber: | 3153371437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0275031 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10101063 | 01 | CDPHP | OTHER | PO10027503 | 01 | EXCELLUS | OTHER | 02692693 | 05 | NY | MEDICAID | 051213000065 | 01 | FIDELIS | OTHER | 385413 | 01 | MVP | OTHER | 6696836 | 01 | GHI | OTHER | 7343747 | 01 | AETNA | OTHER |