Provider Demographics
NPI:1689182578
Name:KUKOSKY, MELISSA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:KUKOSKY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 PATLA RD
Mailing Address - Street 2:
Mailing Address - City:SWEET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18656-2217
Mailing Address - Country:US
Mailing Address - Phone:570-239-0454
Mailing Address - Fax:
Practice Address - Street 1:245 OLD LAKE RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-3154
Practice Address - Country:US
Practice Address - Phone:570-639-1885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008373224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant