Provider Demographics
NPI:1316396245
Name:TAVARES, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:TAVARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GRABLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:679 BIRCH HILL DR
Mailing Address - Street 2:1135 DONINGTON CIRCLE APT. A BALTIMORE MD 21204
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2205
Mailing Address - Country:US
Mailing Address - Phone:908-420-7802
Mailing Address - Fax:
Practice Address - Street 1:9701 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3326
Practice Address - Country:US
Practice Address - Phone:800-465-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT01125225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist