Provider Demographics
NPI:1275805905
Name:PETTY, MELISSA CHRISTIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CHRISTIE
Last Name:PETTY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:CHRISTIE
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:320 ICHORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3600
Mailing Address - Country:US
Mailing Address - Phone:573-881-1418
Mailing Address - Fax:573-774-2487
Practice Address - Street 1:320 ICHORD AVE
Practice Address - Street 2:SUITE F
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3600
Practice Address - Country:US
Practice Address - Phone:573-881-1418
Practice Address - Fax:573-774-2487
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003468225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist