Provider Demographics
NPI:1073608881
Name:AUSTIN, MELANIE B (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:B
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 CROSSBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8724
Mailing Address - Country:US
Mailing Address - Phone:601-668-5390
Mailing Address - Fax:
Practice Address - Street 1:104 WEST RAILROAD AVE. NORTH
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059
Practice Address - Country:US
Practice Address - Phone:601-892-8707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0010225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS670000061OtherPTAN
MSC03445Medicare PIN