Provider Demographics
NPI:1962089193
Name:MOORE, MELISSA (OT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:OT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:ERIKSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:39575 W 10 MILE RD STE 201
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2949
Practice Address - Country:US
Practice Address - Phone:248-516-7250
Practice Address - Fax:248-516-7251
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist