Provider Demographics
NPI:1427539980
Name:HARRIS, MELANIE WANAE (COTA)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:WANAE
Last Name:HARRIS
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 1:4624 BOWIE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-5432
Mailing Address - Country:US
Mailing Address - Phone:432-557-3474
Mailing Address - Fax:
Practice Address - Street 1:3000 MOCKINGBIRD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-1608
Practice Address - Country:US
Practice Address - Phone:432-694-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208001224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant