Provider Demographics
NPI:1073718003
Name:SEVERSON, MELISSA D (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:MUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ANGEL
Mailing Address - State:OR
Mailing Address - Zip Code:97362-9540
Mailing Address - Country:US
Mailing Address - Phone:503-845-2736
Mailing Address - Fax:503-845-9229
Practice Address - Street 1:540 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT ANGEL
Practice Address - State:OR
Practice Address - Zip Code:97362-9540
Practice Address - Country:US
Practice Address - Phone:503-845-2736
Practice Address - Fax:503-845-9229
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR229635225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK114945Medicare PIN