Provider Demographics
NPI:1225138175
Name:KENISON-ROSE, MELISSA M (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:M
Last Name:KENISON-ROSE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:KENISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:2 KNOLLS RD S
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9332
Mailing Address - Country:US
Mailing Address - Phone:518-761-6794
Mailing Address - Fax:
Practice Address - Street 1:2 KNOLLS RD S
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-9332
Practice Address - Country:US
Practice Address - Phone:518-761-6794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014114-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00752456Medicaid