Provider Demographics
NPI:1215181466
Name:KOSTIC, MELISSA ANNE (COTA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANNE
Last Name:KOSTIC
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 1:23 RANDALL PLZ
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-3126
Mailing Address - Country:US
Mailing Address - Phone:845-858-0664
Mailing Address - Fax:
Practice Address - Street 1:2277 GOSHEN TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4032
Practice Address - Country:US
Practice Address - Phone:845-692-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005933-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant