Provider Demographics
NPI:1104937150
Name:MELISA T CROSBY, PT P.A.
Entity type:Organization
Organization Name:MELISA T CROSBY, PT P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-684-9110
Mailing Address - Street 1:885 STATE ROAD 20
Mailing Address - Street 2:
Mailing Address - City:INTERLACHEN
Mailing Address - State:FL
Mailing Address - Zip Code:32148-2430
Mailing Address - Country:US
Mailing Address - Phone:386-684-9110
Mailing Address - Fax:386-684-9255
Practice Address - Street 1:885 STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:INTERLACHEN
Practice Address - State:FL
Practice Address - Zip Code:32148-2430
Practice Address - Country:US
Practice Address - Phone:386-684-9110
Practice Address - Fax:386-684-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 8102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891806600Medicaid