Provider Demographics
NPI:1366857112
Name:VOET, MELINDA (MS, LAT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:VOET
Suffix:
Gender:F
Credentials:MS, LAT
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:BROEREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LAT
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5910
Mailing Address - Fax:920-361-5536
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5910
Practice Address - Fax:920-361-5536
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1590-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1590-39OtherWI STATE ATHLETIC TRAINER LICENSE
MO2012016945OtherMISSOURI STATE ATHLETIC TRAINER LICENSE
2000009495OtherNATABOC