Provider Demographics
NPI:1336214949
Name:MCCOY, MELISSA CHAVERS (OTR L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHAVERS
Last Name:MCCOY
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:CHAVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:4624 SUMMERDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-1368
Mailing Address - Country:US
Mailing Address - Phone:850-994-3456
Mailing Address - Fax:850-994-3476
Practice Address - Street 1:4624 SUMMERDALE BLVD
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:850-994-3476
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10229225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886918900Medicaid