Individual
MELISSA SOUTHARD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1401 PHAY AVE, CANON CITY, CO 81212-2303
(719) 275-8656
Mailing address
25117 SW PARKWAY AVE STE D, WILSONVILLE, OR 97070-9697
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
0000928
CO
224Z00000X
Occupational Therapy Assistant
6144
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000928
COLORADO LICENSE
CO
Enumeration date
04/18/2015
Last updated
01/17/2023
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