Provider Demographics
NPI:1396224986
Name:SEVERTSON, MELINDA SINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SINE
Last Name:SEVERTSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-2278
Mailing Address - Country:US
Mailing Address - Phone:937-325-7671
Mailing Address - Fax:
Practice Address - Street 1:200 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1804
Practice Address - Country:US
Practice Address - Phone:937-767-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-1958225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist