Provider Demographics
NPI:1700599115
Name:MOATS, MELANIE (COTA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MOATS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:5556 N CRIMSON WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2839
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 S ORCHARD ST STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1234
Practice Address - Country:US
Practice Address - Phone:205-908-6116
Practice Address - Fax:208-908-0486
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant