Provider Demographics
NPI:1578634879
Name:GRANDAW, MELINDA R (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:R
Last Name:GRANDAW
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020-0218
Mailing Address - Country:US
Mailing Address - Phone:715-294-2111
Mailing Address - Fax:715-294-5758
Practice Address - Street 1:2600 65TH AVENUE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:WI
Practice Address - Zip Code:54020-4370
Practice Address - Country:US
Practice Address - Phone:715-294-2111
Practice Address - Fax:715-294-5758
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4827-26225X00000X
MN100675225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist