Provider Demographics
NPI:1922399427
Name:NICKESRON, MELISSA MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:NICKESRON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 DICKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1601
Mailing Address - Country:US
Mailing Address - Phone:978-551-1661
Mailing Address - Fax:
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:BLDG 9
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-552-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1929225X00000X
MA4036225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist