Provider Demographics
NPI:1700696523
Name:MICULKA, MELISSA SENA (LMT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SENA
Last Name:MICULKA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 S 11TH ST W APT A
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4874
Mailing Address - Country:US
Mailing Address - Phone:406-223-0721
Mailing Address - Fax:
Practice Address - Street 1:1630 S 11TH ST W APT A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4874
Practice Address - Country:US
Practice Address - Phone:406-223-0721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT53225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist