Provider Demographics
NPI:1700283934
Name:LOVELACE, MALYSSA
Entity Type:Individual
Prefix:
First Name:MALYSSA
Middle Name:
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALYSSA
Other - Middle Name:J
Other - Last Name:SCHOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5685 EDEN VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1203
Mailing Address - Country:US
Mailing Address - Phone:317-297-7880
Mailing Address - Fax:
Practice Address - Street 1:5685 EDEN VILLAGE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1203
Practice Address - Country:US
Practice Address - Phone:317-297-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005361A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist