Basic Information
| Provider Information | |||||||||
| NPI: | 1356775233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEHALIC | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KRASNIAK | ||||||||
| OtherFirstName: | KRASNIAK | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4533 BRAMBLETON AVE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240183436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 VALLEY GATEWAY BLVD STE A3 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240126859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 62036789 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305208287 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.