Provider Demographics
NPI:1699984740
Name:MAZUREK, MELINDA KATHRYN (PT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:KATHRYN
Last Name:MAZUREK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5374 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-8112
Mailing Address - Country:US
Mailing Address - Phone:414-529-9780
Mailing Address - Fax:
Practice Address - Street 1:5374 BALBOA DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-8112
Practice Address - Country:US
Practice Address - Phone:414-529-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2676024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40141400Medicaid