Provider Demographics
NPI:1144768854
Name:WICIAK, MELINDA SUE (OT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:WICIAK
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 1:1560 HENTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1371
Mailing Address - Country:US
Mailing Address - Phone:419-866-5196
Mailing Address - Fax:419-866-5663
Practice Address - Street 1:1560 HENTHORNE DR
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1371
Practice Address - Country:US
Practice Address - Phone:419-866-5196
Practice Address - Fax:419-866-5663
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT004776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0392980Medicaid
OH1609899061OtherCOMPANY NPI