Provider Demographics
NPI:1528325941
Name:BRAUCHT, MELISSA LEO (PT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LEO
Last Name:BRAUCHT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11588 SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1335 CYPRESS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3537
Practice Address - Country:US
Practice Address - Phone:909-305-1383
Practice Address - Fax:909-305-1435
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist