1104937135 NPI number — MELISA T CROSBY PT

Table of content: MELISA T CROSBY PT (NPI 1104937135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104937135 NPI number — MELISA T CROSBY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSBY
Provider First Name:
MELISA
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104937135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505A ATLANTIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INTERLACHEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32148-5433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-684-9110
Provider Business Mailing Address Fax Number:
386-684-9255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505A ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INTERLACHEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32148-5433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-684-9110
Provider Business Practice Location Address Fax Number:
386-684-9255
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 8102 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y931D . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8853835 00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y8180 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 885383500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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