Provider Demographics
NPI:1417119264
Name:WICK, MELISSA ELAINE (PT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ELAINE
Last Name:WICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2201
Mailing Address - Country:US
Mailing Address - Phone:715-802-5099
Mailing Address - Fax:715-802-5100
Practice Address - Street 1:105 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2201
Practice Address - Country:US
Practice Address - Phone:715-802-5099
Practice Address - Fax:715-802-5100
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5146-024225100000X
WI777-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist