Provider Demographics
NPI:1700166212
Name:SUSALKA, MELISSA A (COTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:SUSALKA
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 1:45 VALHALLA FARM RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NH
Mailing Address - Zip Code:03244-7110
Mailing Address - Country:US
Mailing Address - Phone:603-345-0409
Mailing Address - Fax:
Practice Address - Street 1:45 VALHALLA FARM RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NH
Practice Address - Zip Code:03244-7110
Practice Address - Country:US
Practice Address - Phone:603-345-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0623224Z00000X
VA0131000904224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant