Provider Demographics
NPI:1093994907
Name:FORD, MELISSA (OT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAUREN DR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2507
Mailing Address - Country:US
Mailing Address - Phone:662-720-1007
Mailing Address - Fax:662-720-1007
Practice Address - Street 1:100 LAUREN DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2507
Practice Address - Country:US
Practice Address - Phone:662-720-1007
Practice Address - Fax:662-720-1007
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist