=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386690352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELINDA J BRUER OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 01/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 W TYRONE RD
-----------------------------------------------------
City | OAK RIDGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37830-6517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-276-3852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 HOLDER CEMETERY RD
-----------------------------------------------------
City | TELLICO PLAINS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37385-5997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-309-5658
-----------------------------------------------------
Fax | 423-261-2159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 197786
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 000339
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------