Provider Demographics
NPI:1639311392
Name:MELBOURNE THERAPY CLINIC INC
Entity Type:Organization
Organization Name:MELBOURNE THERAPY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:870-368-4774
Mailing Address - Street 1:PO BOX 814
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-0814
Mailing Address - Country:US
Mailing Address - Phone:870-368-4774
Mailing Address - Fax:870-368-4773
Practice Address - Street 1:701 MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-4774
Practice Address - Fax:870-368-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138707721Medicaid
AR5G198OtherMEDICARE