Provider Demographics
NPI:1528630506
Name:GRESHAM, MELISSA (MS, ATC, LAT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 WHITFORD DR MURRAY ATHLETIC TRAINING ROOM
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27708-0001
Mailing Address - Country:US
Mailing Address - Phone:919-668-5741
Mailing Address - Fax:
Practice Address - Street 1:151 WHITFORD DR MURRAY ATHLETIC TRAINING ROOM
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27708-0001
Practice Address - Country:US
Practice Address - Phone:919-668-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-21582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer