Provider Demographics
NPI:1043420334
Name:SMITH, MELISSA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:DODGE-FORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:2506 S 127TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2603
Mailing Address - Country:US
Mailing Address - Phone:402-238-6908
Mailing Address - Fax:
Practice Address - Street 1:11850 NICHOLAS ST STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154
Practice Address - Country:US
Practice Address - Phone:402-577-0496
Practice Address - Fax:402-933-4905
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist