Basic Information
| Provider Information | |||||||||
| NPI: | 1730147349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRAG | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LARA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PORTNOY | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LARA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 545 PAWTUCKET AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028606046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014755775 | ||||||||
| FaxNumber: | 7818287951 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 PAWTUCKET AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028606046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014755775 | ||||||||
| FaxNumber: | 7818287951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT02125 | RI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9543 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.