Provider Demographics
NPI:1497202998
Name:FRY, MELISSA (OTR)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N61W15150 WIGWAM DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-5835
Mailing Address - Country:US
Mailing Address - Phone:414-640-3091
Mailing Address - Fax:
Practice Address - Street 1:2901 WEST KINNICKINNIC PARKWAY
Practice Address - Street 2:SUITE 500
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-1628
Practice Address - Country:US
Practice Address - Phone:414-649-3251
Practice Address - Fax:414-649-3245
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3342-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist