Provider Demographics
NPI:1063538452
Name:CHANCELLOR, MELINDA DANETTE (PT)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:DANETTE
Last Name:CHANCELLOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MELINDA
Other - Middle Name:DANETTE
Other - Last Name:GOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:726 REID RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-9629
Mailing Address - Country:US
Mailing Address - Phone:601-649-5927
Mailing Address - Fax:601-426-4768
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4119
Practice Address - Fax:601-426-4768
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist