Provider Demographics
NPI:1790239069
Name:JUSTICE-WEST, MELISSA RENAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENAE
Last Name:JUSTICE-WEST
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:RENAE
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:613 BRIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-8545
Mailing Address - Country:US
Mailing Address - Phone:606-205-0350
Mailing Address - Fax:
Practice Address - Street 1:613 BRIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-8545
Practice Address - Country:US
Practice Address - Phone:606-205-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5305225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist