Provider Demographics
NPI:1194368217
Name:RECORE, MELANIE LYNN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:LYNN
Last Name:RECORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:MENLANIE
Other - Middle Name:LYNN
Other - Last Name:BARDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16625 EVENSON RD
Mailing Address - Street 2:
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245-9759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 S. ALVERNO ROAD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-9208
Practice Address - Country:US
Practice Address - Phone:920-683-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XG0600X, 225XP0019X
WI6625-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102503Medicaid