Provider Demographics
NPI:1699081059
Name:KING, MELISSA JEAN (PT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JEAN
Last Name:KING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:WIEDMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:300 TOWER ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9403
Mailing Address - Country:US
Mailing Address - Phone:770-218-0219
Mailing Address - Fax:770-514-6744
Practice Address - Street 1:300 TOWER ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9403
Practice Address - Country:US
Practice Address - Phone:770-499-9918
Practice Address - Fax:770-792-8276
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist