Provider Demographics
NPI:1215692439
Name:MARTINEZ, MELISSA JOY
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOY
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3242
Mailing Address - Country:US
Mailing Address - Phone:262-939-2839
Mailing Address - Fax:
Practice Address - Street 1:3216 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3252
Practice Address - Country:US
Practice Address - Phone:414-344-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3231-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant