Provider Demographics
NPI:1053652248
Name:NOONAN, MELLISSA MARY (OTR)
Entity type:Individual
Prefix:
First Name:MELLISSA
Middle Name:MARY
Last Name:NOONAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2190
Mailing Address - Country:US
Mailing Address - Phone:203-879-8066
Mailing Address - Fax:
Practice Address - Street 1:50 BEACH RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1902
Practice Address - Country:US
Practice Address - Phone:203-879-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004025225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist