Provider Demographics
NPI:1821351297
Name:WILSON, MELISA ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 E SHERRI DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3643
Mailing Address - Country:US
Mailing Address - Phone:480-570-4157
Mailing Address - Fax:
Practice Address - Street 1:851 E SHERRI DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3643
Practice Address - Country:US
Practice Address - Phone:480-570-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2546172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker