Provider Demographics
NPI:1164993077
Name:PENCA, MELANIE (COTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:PENCA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MEADOWLAWN DR UNIT 11
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6248
Mailing Address - Country:US
Mailing Address - Phone:440-974-1862
Mailing Address - Fax:
Practice Address - Street 1:339 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2593
Practice Address - Country:US
Practice Address - Phone:330-498-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007271224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant