Provider Demographics
NPI:1992263214
Name:MILLER, MELINDA (COTA/L)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 FOXFIRE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7806
Mailing Address - Country:US
Mailing Address - Phone:757-753-2682
Mailing Address - Fax:
Practice Address - Street 1:900 N RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3721
Practice Address - Country:US
Practice Address - Phone:217-789-0930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005144224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant