Healthcare Provider Details

I. General information

NPI: 1639678931
Provider Name (Legal Business Name): MELISSIA CUDDEBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 RECTOR RD
GLENVILLE NY
12302-6709
US

IV. Provider business mailing address

1025 RECTOR RD
GLENVILLE NY
12302-6709
US

V. Phone/Fax

Practice location:
  • Phone: 518-928-2331
  • Fax: 518-928-2331
Mailing address:
  • Phone: 518-928-2331
  • Fax: 518-928-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number008552-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: