Provider Demographics
NPI:1740652585
Name:HARRIS, MELISSA A (COTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:HARRIS
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 1:1625 PINE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-4857
Mailing Address - Country:US
Mailing Address - Phone:276-237-0989
Mailing Address - Fax:
Practice Address - Street 1:179 COMBS ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-8429
Practice Address - Country:US
Practice Address - Phone:336-372-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10009224Z00000X
VA0131001503224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant