Provider Demographics
NPI:1265980718
Name:GARDNER, MELISSA BLAIR (COTA/L)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:BLAIR
Last Name:GARDNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:BLAIR
Other - Last Name:STILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:3960 NEW COVINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2504
Mailing Address - Country:US
Mailing Address - Phone:901-516-5320
Mailing Address - Fax:
Practice Address - Street 1:3960 NEW COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2504
Practice Address - Country:US
Practice Address - Phone:901-516-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02386224Z00000X
TN2374224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant