Healthcare Provider Details

I. General information

NPI: 1689558546
Provider Name (Legal Business Name): ELIZABETH MARIE MELLOW OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 E 12TH ST
DOUGLAS AZ
85607-2337
US

IV. Provider business mailing address

PO BOX 477
PEARCE AZ
85625-0477
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-2447
  • Fax: 520-762-4384
Mailing address:
  • Phone: 520-895-1968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-009238
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: