Provider Demographics
NPI:1497963508
Name:MELLO, LISA KRISTEN (COTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:KRISTEN
Last Name:MELLO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:27190 STARK ST
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2045
Mailing Address - Country:US
Mailing Address - Phone:619-508-4066
Mailing Address - Fax:
Practice Address - Street 1:250 INTERNATIONAL PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5030
Practice Address - Country:US
Practice Address - Phone:800-509-5872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC00001187224Z00000X
CA721224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant