Provider Demographics
NPI:1639122674
Name:FORTENBERRY, MELISSA M (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:M
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10902 OASIS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-5030
Mailing Address - Country:US
Mailing Address - Phone:713-721-9609
Mailing Address - Fax:
Practice Address - Street 1:4141 SOUTHWEST FWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7313
Practice Address - Country:US
Practice Address - Phone:713-669-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107939225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX107939OtherLISCENSE
TX1016955OtherBLUE LINK NUMBER
TXP00357763OtherRAILROAD MEDICARE PROVIDE
TX107939OtherLISCENSE