Provider Demographics
NPI:1194337279
Name:CASSIDY, MELISSA MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:HAJKALUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:47 NICHOLS AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1927
Mailing Address - Country:US
Mailing Address - Phone:818-602-5605
Mailing Address - Fax:
Practice Address - Street 1:175 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4357
Practice Address - Country:US
Practice Address - Phone:203-789-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48.004682225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist