Provider Demographics
NPI:1285302711
Name:MABRY, MELISSA STEPHANI-ELLEN (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:STEPHANI-ELLEN
Last Name:MABRY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW MT CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-1012
Mailing Address - Country:US
Mailing Address - Phone:479-340-0095
Mailing Address - Fax:
Practice Address - Street 1:3800 SW MT CARMEL DR
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72713-1012
Practice Address - Country:US
Practice Address - Phone:479-340-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR3535225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist