Provider Demographics
NPI:1760280481
Name:MELLECKER, TYLER EMERSON (PTA)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:EMERSON
Last Name:MELLECKER
Suffix:
Gender:
Credentials:PTA
Other - Prefix:MR
Other - First Name:TYLER
Other - Middle Name:EMERSON
Other - Last Name:MELLECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TYLER E MELLECKER
Mailing Address - Street 1:20973 CORKSCREW SHORES BLVD
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9146
Mailing Address - Country:US
Mailing Address - Phone:630-687-0574
Mailing Address - Fax:239-320-3231
Practice Address - Street 1:20973 CORKSCREW SHORES BLVD
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9146
Practice Address - Country:US
Practice Address - Phone:630-687-0574
Practice Address - Fax:239-320-3231
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27302261QP2000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy