Provider Demographics
NPI:1992159750
Name:WILCOWSKI, MELISSA SUE (CMT, NCBTMB)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:WILCOWSKI
Suffix:
Gender:F
Credentials:CMT, NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 230TH ST E
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8292
Mailing Address - Country:US
Mailing Address - Phone:701-212-2586
Mailing Address - Fax:
Practice Address - Street 1:12100 SINGLETREE LN STE 198
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7961
Practice Address - Country:US
Practice Address - Phone:952-607-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist