Basic Information
| Provider Information | |||||||||
| NPI: | 1356675805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4112 46TH AVE | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612017166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097792828 | ||||||||
| FaxNumber: | 3097792839 | ||||||||
| Practice Location | |||||||||
| Address1: | 4112 46TH AVE | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612017166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097792828 | ||||||||
| FaxNumber: | 3097792839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 09/30/2009 | ||||||||
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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 | 070012458 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.