Provider Demographics
NPI:1891403267
Name:CARROLL, MELANIE NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:NICOLE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIBERTY PKWY APT B10
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-4900
Mailing Address - Country:US
Mailing Address - Phone:662-931-2777
Mailing Address - Fax:
Practice Address - Street 1:113 LIBERTY PKWY APT B10
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-4900
Practice Address - Country:US
Practice Address - Phone:662-931-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOTA-3887224Z00000X
TN3794224Z00000X
MO2022031203224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant