=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346721388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE LUCIUS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2018
-----------------------------------------------------
Last Update Date | 10/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2550 S STATE ROUTE 100
-----------------------------------------------------
City | TIFFIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44883-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-447-7203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2021 S COUNTY ROAD 7
-----------------------------------------------------
City | TIFFIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44883-9379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-207-5780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 009692
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------