Provider Demographics
NPI:1104130046
Name:MULLIGAN, MELINDA R (OT)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:R
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 NE 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2614
Mailing Address - Country:US
Mailing Address - Phone:503-481-3900
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:STE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:503-570-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1042879225X00000X
WA00004580225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist