Active NPI
Melissa Marie Tietze, COTA
- Occupational Therapy Assistant
- Benton, AR
National Provider Identifier
1053621201
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- OT-A869
- Practice address
- 17706 I-30 Ste 3
Benton, AR 72019-2930 - Phone
- (501) 315-4414
- Fax
- (501) 315-3467
- NPI assigned
- Oct 20, 2010
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | OT-A869 | AR | Primary |
Addresses
Primary practice location
17706 I-30 Ste 3
Benton, AR 72019-2930
Mailing address
17706 I-30 Ste 3
Benton, AR 72019-2930
Phone (501) 315-4414
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| OT-A869 | AR | MD | Occupational Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1287532800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1408406400000",
"number": "1053621201",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "17706 I-30 STE 3",
"city": "BENTON",
"state": "AR",
"postal_code": "720192930",
"telephone_number": "501-315-4414",
"fax_number": "501-315-3467"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "17706 I-30 STE 3",
"city": "BENTON",
"state": "AR",
"postal_code": "720192930",
"telephone_number": "501-315-4414",
"fax_number": "501-315-3467"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIETZE",
"first_name": "MELISSA",
"middle_name": "MARIE",
"name_prefix": "Miss",
"credential": "COTA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2010-10-20",
"last_updated": "2014-08-19",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "AR",
"license": "OT-A869",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Benton, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.