Provider Demographics
NPI:1376900480
Name:MELLENDORF, EMILY (OTRL)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MELLENDORF
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9090 CAYUGA DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3202
Mailing Address - Country:US
Mailing Address - Phone:248-897-1785
Mailing Address - Fax:
Practice Address - Street 1:9090 CAYUGA DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-3202
Practice Address - Country:US
Practice Address - Phone:248-897-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist