Provider Demographics
NPI:1134691579
Name:MELLYNCHUK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MELLYNCHUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NALLEY TERRANCE
Mailing Address - Street 2:ROOM 16
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 NALLEY TERRANCE
Practice Address - Street 2:ROOM 16
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:240-696-3218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist