Provider Demographics
NPI:1154501716
Name:KNICKERBOCKER, MELISSA J (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:J
Last Name:KNICKERBOCKER
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 1:422 WESTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3214
Practice Address - Country:US
Practice Address - Phone:860-378-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003222225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist