Provider Demographics
NPI:1679765044
Name:GRAY, MELISSA G (OTRL)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:G
Last Name:GRAY
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:G
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1801 W MAUMEE ST STE 125
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:517-264-6141
Practice Address - Fax:517-263-5786
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008089225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist