Provider Demographics
NPI:1003956103
Name:HARDY, MELISSA MICHELLE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MICHELLE
Last Name:HARDY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:MICHELLE
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:20409 N 17TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4306
Mailing Address - Country:US
Mailing Address - Phone:623-328-7352
Mailing Address - Fax:
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0080225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626765Medicaid