Provider Demographics
NPI:1831377902
Name:WITTENBURG, MELISSA JANE (MSOT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:WITTENBURG
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOT
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2929
Mailing Address - Country:US
Mailing Address - Phone:319-352-5644
Mailing Address - Fax:
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2929
Practice Address - Country:US
Practice Address - Phone:319-352-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist