Provider Demographics
NPI:1255061990
Name:DIZON, MELISSA KIRSTIE CRUZ (PTA)
Entity type:Individual
Prefix:
First Name:MELISSA KIRSTIE
Middle Name:CRUZ
Last Name:DIZON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:DIZON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:20201 CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1010
Mailing Address - Country:US
Mailing Address - Phone:708-852-2540
Mailing Address - Fax:708-503-3221
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-852-2540
Practice Address - Fax:708-503-3221
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008545225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant