Provider Demographics
NPI:1366574949
Name:ANDERSON, MELISSA MOORE (PT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MOORE
Last Name:ANDERSON
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 1:1777 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-5196
Mailing Address - Country:US
Mailing Address - Phone:717-574-5416
Mailing Address - Fax:
Practice Address - Street 1:115 S SAINT JOHNS DR
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4147
Practice Address - Country:US
Practice Address - Phone:717-761-4754
Practice Address - Fax:717-370-6315
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT005690L225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000528211OtherPHYSICAL THERAPIST
PA0019275810001Medicaid
PA1037051190001Medicaid