Provider Demographics
NPI:1407424914
Name:LANE, MELISSA (COTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 PURRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6727
Mailing Address - Country:US
Mailing Address - Phone:757-201-2048
Mailing Address - Fax:
Practice Address - Street 1:421 SQUIRE POPE RD
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-1229
Practice Address - Country:US
Practice Address - Phone:843-342-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5264224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant