Provider Demographics
NPI:1962641118
Name:PINEDA, MELISSA JUNE LICUPA (PT)
Entity type:Individual
Prefix:
First Name:MELISSA JUNE
Middle Name:LICUPA
Last Name:PINEDA
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:MELISSA JUNE
Other - Middle Name:N
Other - Last Name:LICUPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1079 S MAIN ST APT 137
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4831
Mailing Address - Country:US
Mailing Address - Phone:574-306-7683
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342
Practice Address - Country:US
Practice Address - Phone:219-947-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009769A171W00000X, 225100000X
MD21483171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No171W00000XOther Service ProvidersContractor