Provider Demographics
NPI:1013269299
Name:MCDIVITT, MELISSA DOLORES (COTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DOLORES
Last Name:MCDIVITT
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 1:977 BIRCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-6478
Mailing Address - Country:US
Mailing Address - Phone:321-480-1274
Mailing Address - Fax:
Practice Address - Street 1:128 FRANCES MEEKS WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3983
Practice Address - Country:US
Practice Address - Phone:912-727-2321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001464224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant