Provider Demographics
NPI:1073901781
Name:OWENS, MELLISA NICHOLE (COTA)
Entity Type:Individual
Prefix:
First Name:MELLISA
Middle Name:NICHOLE
Last Name:OWENS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 LAUREL BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256
Mailing Address - Country:US
Mailing Address - Phone:276-865-4229
Mailing Address - Fax:
Practice Address - Street 1:676 LAUREL BRANCH
Practice Address - Street 2:
Practice Address - City:HAYSI
Practice Address - State:VA
Practice Address - Zip Code:24256
Practice Address - Country:US
Practice Address - Phone:276-865-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000626224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant