Provider Demographics
NPI:1003199407
Name:TELLO BAZALAR, MELISSA LISSETH (MS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LISSETH
Last Name:TELLO BAZALAR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PELHAM RD APT 6L
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10805-3119
Mailing Address - Country:US
Mailing Address - Phone:347-666-3485
Mailing Address - Fax:
Practice Address - Street 1:140 PELHAM RD APT 6L
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10805-3119
Practice Address - Country:US
Practice Address - Phone:347-666-3485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist