Basic Information
| Provider Information | |||||||||
| NPI: | 1356569701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 CALVIN CIR | ||||||||
| Address2: | |||||||||
| City: | VALLEY GRANDE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367038801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348752550 | ||||||||
| FaxNumber: | 3348753654 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 EXECUTIVE PARK LN | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367017734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348752550 | ||||||||
| FaxNumber: | 3348753654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1846 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.