Provider Demographics
NPI:1730846775
Name:MALINE, MELISSA R (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:MALINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:110 CASTLEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E LIONS CLUB DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4356
Practice Address - Country:US
Practice Address - Phone:573-375-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2018033720225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant