Basic Information
| Provider Information | |||||||||
| NPI: | 1538445796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 ROE ST | ||||||||
| Address2: | #18 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481706264 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 S LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH LYON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481781407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484861110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2011 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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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 | 2255A2300X | 2601000053 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 22 | 01 | RESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS | OTHER |