Provider Demographics
NPI:1790769198
Name:FORNCROOK, MELISSA MARIE (OT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:FORNCROOK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5313
Mailing Address - Country:US
Mailing Address - Phone:831-375-1885
Mailing Address - Fax:831-375-7436
Practice Address - Street 1:5910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4704
Practice Address - Country:US
Practice Address - Phone:209-475-1000
Practice Address - Fax:209-475-1809
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 4216225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26595ZMedicare ID - Type Unspecified