Provider Demographics
NPI:1588389621
Name:FENTON, MELISSA LORRAINE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LORRAINE
Last Name:FENTON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 BROOK ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5828
Mailing Address - Country:US
Mailing Address - Phone:631-697-2573
Mailing Address - Fax:
Practice Address - Street 1:1038 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3208
Practice Address - Country:US
Practice Address - Phone:631-368-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027303225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics