Provider Demographics
NPI:1932468139
Name:CLARKE, MELISSA LYNNE (OTR, MOT)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNNE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:OTR, MOT
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:LYNNE
Other - Last Name:DANDIGNAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR, MOT
Mailing Address - Street 1:9101 BURNET RD STE 103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5260
Mailing Address - Country:US
Mailing Address - Phone:512-248-2422
Mailing Address - Fax:512-248-2354
Practice Address - Street 1:1301 MEDICAL PKWY STE 130
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2529
Practice Address - Country:US
Practice Address - Phone:512-248-2422
Practice Address - Fax:512-248-2354
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
TX114267225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX294270804Medicaid
TX294270803Medicaid