Provider Demographics
NPI:1548805575
Name:MALLORY, MELISSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19630 LAKE OSCEOLA LN
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-1709
Mailing Address - Country:US
Mailing Address - Phone:813-992-6857
Mailing Address - Fax:
Practice Address - Street 1:13719 DALLAS DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7133
Practice Address - Country:US
Practice Address - Phone:727-862-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT20328225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist