Provider Demographics
NPI:1043684798
Name:STALLBAUMER, MELINDA ANN (COTA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:ANN
Last Name:STALLBAUMER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:ANN
Other - Last Name:PARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1823 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3381
Mailing Address - Country:US
Mailing Address - Phone:785-776-3322
Mailing Address - Fax:
Practice Address - Street 1:1823 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3381
Practice Address - Country:US
Practice Address - Phone:785-776-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01245224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS18-01245OtherNONE