Provider Demographics
NPI:1922120922
Name:LOCKWOOD, MELISSA MARIE (OTRL)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18512-2815
Mailing Address - Country:US
Mailing Address - Phone:570-362-3373
Mailing Address - Fax:570-344-4090
Practice Address - Street 1:601 BUTLER ST
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-2815
Practice Address - Country:US
Practice Address - Phone:570-362-3373
Practice Address - Fax:570-344-4090
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003647L171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018636260001Medicaid