Provider Demographics
NPI:1245362060
Name:DAUL, MELISSA LYNN (OTR)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:DAUL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:THURMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:5210 HIGHLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1970
Practice Address - Country:US
Practice Address - Phone:248-674-9560
Practice Address - Fax:248-674-9562
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006640225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750051Medicare PIN
MIMI6211044Medicare PIN