Provider Demographics
NPI:1588333538
Name:MCLISTER, MELISSA (MSOT, OTR)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCLISTER
Suffix:
Gender:F
Credentials:MSOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 BRUMSEY CT SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-5802
Mailing Address - Country:US
Mailing Address - Phone:860-604-8678
Mailing Address - Fax:
Practice Address - Street 1:7550 ASSISI HTS
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3853
Practice Address - Country:US
Practice Address - Phone:719-598-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-12
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist