Provider Demographics
NPI:1962587931
Name:BRUNELLE, MELISSA A (PT)
Entity type:Individual
Prefix:MR
First Name:MELISSA
Middle Name:A
Last Name:BRUNELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:872 SMITHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-3500
Mailing Address - Country:US
Mailing Address - Phone:401-722-0012
Mailing Address - Fax:401-722-0056
Practice Address - Street 1:1822 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-8938
Practice Address - Country:US
Practice Address - Phone:401-354-6700
Practice Address - Fax:401-354-6702
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI22476-7OtherBCBS
RI409454OtherBLUE CHIP
RIP61482Medicare UPIN