Provider Demographics
NPI:1750636312
Name:OTTEN, MELISSA MARIE (PT)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:OTTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 SIGMON WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4847
Mailing Address - Country:US
Mailing Address - Phone:513-858-1218
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH016096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1750636312Medicaid
OH1750636312Medicaid