Provider Demographics
NPI:1821112921
Name:SMITH, MELISSA (OTR)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N CRESTWAY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3839
Mailing Address - Country:US
Mailing Address - Phone:316-250-0225
Mailing Address - Fax:316-685-4189
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:STE 304
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-1505
Practice Address - Country:US
Practice Address - Phone:316-250-0225
Practice Address - Fax:316-685-4189
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1700369225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist