Provider Demographics
NPI:1417060930
Name:PEABODY, MELISSA M (PT, CHT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:M
Last Name:PEABODY
Suffix:
Gender:F
Credentials:PT, CHT
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:GURSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, CHT
Mailing Address - Street 1:1608 ROUTE 88 W
Mailing Address - Street 2:SUITE 112
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3009
Mailing Address - Country:US
Mailing Address - Phone:732-840-8100
Mailing Address - Fax:732-840-0559
Practice Address - Street 1:1608 ROUTE 88 W
Practice Address - Street 2:SUITE 112
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3009
Practice Address - Country:US
Practice Address - Phone:732-840-8100
Practice Address - Fax:732-840-0559
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004018750225100000X
NJ40QA00650800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO218841802Medicare ID - Type UnspecifiedCMS PROV.#