Provider Demographics
NPI:1760693907
Name:CLEMENTS, MELANIE M (OTRL)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:M
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:C
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:704 BLOOMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2025
Mailing Address - Country:US
Mailing Address - Phone:502-331-5478
Mailing Address - Fax:502-348-9825
Practice Address - Street 1:704 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2025
Practice Address - Country:US
Practice Address - Phone:502-331-5478
Practice Address - Fax:502-348-9825
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R1473225XP0200X
KY135224225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000001033112OtherANTHEM
KY7100400430Medicaid
KY50116410OtherPASSPORT HEALTH