Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 6625-26 | WI |
N | 225XG0600X | Occupational Therapist - Gerontology | ||
N | 225XP0019X | Occupational Therapist - Physical Rehabilitation |
NPI | 1194368217 |
---|---|
Provider Name | Mrs. Melanie Lynn Recore |
First Address | Valders, WI 54245-9759 |
Second Address | Manitowoc, WI 54220-9208 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2019 |
Last Update Date | 15/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100102503 | (05) | WI |