Provider Demographics
NPI:1063788156
Name:KONECHNE, MELISSA SUE (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:KONECHNE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 N MAJOR DR
Mailing Address - Street 2:608
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77713-8545
Mailing Address - Country:US
Mailing Address - Phone:651-402-0902
Mailing Address - Fax:
Practice Address - Street 1:1905 1/2 5TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566
Practice Address - Country:US
Practice Address - Phone:608-329-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1857-19225200000X
MNA1489225200000X
TX2117739225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant