Provider Demographics
NPI:1134600869
Name:SMITH, MELISSA MARIA (OT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 SHALLOWBEND DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-6972
Mailing Address - Country:US
Mailing Address - Phone:817-715-4381
Mailing Address - Fax:
Practice Address - Street 1:1361 SHALLOWBEND DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-6972
Practice Address - Country:US
Practice Address - Phone:817-715-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist