Provider Demographics
NPI:1093904401
Name:SMITH, MELISSA MOTT (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MOTT
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:KRISTINE
Other - Last Name:MOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:9055 SW SUNSTEAD LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-2536
Mailing Address - Country:US
Mailing Address - Phone:720-220-3454
Mailing Address - Fax:
Practice Address - Street 1:9055 SW SUNSTEAD LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2536
Practice Address - Country:US
Practice Address - Phone:720-220-3454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1041340225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist