Provider Demographics
NPI:1689035644
Name:FACKLER, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FACKLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18887 COUNTY ROAD 1150
Mailing Address - Street 2:
Mailing Address - City:PIONEER
Mailing Address - State:OH
Mailing Address - Zip Code:43554-9705
Mailing Address - Country:US
Mailing Address - Phone:260-460-7819
Mailing Address - Fax:
Practice Address - Street 1:18887 COUNTY ROAD 1150
Practice Address - Street 2:
Practice Address - City:PIONEER
Practice Address - State:OH
Practice Address - Zip Code:43554-9705
Practice Address - Country:US
Practice Address - Phone:260-460-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06396224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant