Provider Demographics
NPI:1053879130
Name:GREENE, MELISSA LYNNE (OTR/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNNE
Last Name:GREENE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5042 GLADSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1309
Mailing Address - Country:US
Mailing Address - Phone:612-799-4315
Mailing Address - Fax:
Practice Address - Street 1:1401 E 100TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2615
Practice Address - Country:US
Practice Address - Phone:952-888-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105860225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist