Provider Demographics
NPI:1003598111
Name:PETERS, MELANIE ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ROSE
Last Name:PETERS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:ROSE
Other - Last Name:CISLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1308 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1308 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1606
Practice Address - Country:US
Practice Address - Phone:920-388-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7239-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist