Provider Demographics
NPI:1639488794
Name:DAS-GORDZIEJ, MELISSA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:DAS-GORDZIEJ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GORDZIEJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1926 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-2729
Mailing Address - Country:US
Mailing Address - Phone:920-451-0742
Mailing Address - Fax:
Practice Address - Street 1:2600 KILEY WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-5020
Practice Address - Country:US
Practice Address - Phone:920-449-7304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI349526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist