Provider Demographics
NPI:1508367681
Name:KIRN, MELISSA ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KIRN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 W WARNER AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1912
Mailing Address - Country:US
Mailing Address - Phone:219-670-3515
Mailing Address - Fax:
Practice Address - Street 1:3431 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3129
Practice Address - Country:US
Practice Address - Phone:510-534-8540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4782224Z00000X
IL057.004468224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant