Provider Demographics
NPI:1528081361
Name:WILSON, MELISSA LYNN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CONOWINGO
Mailing Address - State:MD
Mailing Address - Zip Code:21918-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:00 AVENUE D
Practice Address - Street 2:BUILDING 24
Practice Address - City:PERRY POINT
Practice Address - State:MD
Practice Address - Zip Code:21902
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1018317225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist