Provider Demographics
NPI:1518219088
Name:WEAVER WAKEFIELD, MELANIE SUSAN (COTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:SUSAN
Last Name:WEAVER WAKEFIELD
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 1:3860 IRISH RD
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-9764
Mailing Address - Country:US
Mailing Address - Phone:716-778-4676
Mailing Address - Fax:
Practice Address - Street 1:11390 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1017
Practice Address - Country:US
Practice Address - Phone:716-580-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004032-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant