Provider Demographics
NPI:1992416036
Name:REYNOLDS, MELISSA (COTA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:REYNOLDS
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 1:4867 W LOWER BEND DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2072
Mailing Address - Country:US
Mailing Address - Phone:801-455-9744
Mailing Address - Fax:
Practice Address - Street 1:867 S 800 W
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4505
Practice Address - Country:US
Practice Address - Phone:801-785-9019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371464-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant