Provider Demographics
NPI:1750052346
Name:SOUTHWORTH, MELANIE GRACE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:GRACE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E 28TH TER APT 15
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-3342
Mailing Address - Country:US
Mailing Address - Phone:816-885-0506
Mailing Address - Fax:
Practice Address - Street 1:2901 TROOST AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1538
Practice Address - Country:US
Practice Address - Phone:816-418-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist