Provider Demographics
NPI:1083493894
Name:VAN OMEN, MELISSA JEAN (MSOT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:VAN OMEN
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9676 BINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-9464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:269-359-3735
Practice Address - Street 1:45 N WHITTAKER ST STE 204
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-1173
Practice Address - Country:US
Practice Address - Phone:269-235-9821
Practice Address - Fax:269-359-3735
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014673225X00000X
MI5201011333225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist