Provider Demographics
NPI:1619312436
Name:PERRY, MELODIE SUE (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MELODIE
Middle Name:SUE
Last Name:PERRY
Suffix:
Gender:F
Credentials:MS, 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 191
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-0191
Mailing Address - Country:US
Mailing Address - Phone:423-915-6307
Mailing Address - Fax:423-328-8662
Practice Address - Street 1:1319 SUNSET DR
Practice Address - Street 2:SUITE 102
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3799
Practice Address - Country:US
Practice Address - Phone:423-915-6307
Practice Address - Fax:423-328-8662
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4137225X00000X, 225XP0200X
VA0119006020225X00000X, 225XP0200X, 252Y00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No252Y00000XAgenciesEarly Intervention Provider Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services