Provider Demographics
NPI:1124386362
Name:WALLINGTON, MELISSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WALLINGTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2697
Practice Address - Country:US
Practice Address - Phone:810-519-8227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006637225X00000X
WI4802026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist