Provider Demographics
NPI:1063629632
Name:DAVIS, MELISSA LONG (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LONG
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 HIGHWAY 389
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-8451
Mailing Address - Country:US
Mailing Address - Phone:662-769-4888
Mailing Address - Fax:662-338-5439
Practice Address - Street 1:1411 HIGHWAY 389
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-8451
Practice Address - Country:US
Practice Address - Phone:662-769-4888
Practice Address - Fax:662-338-5439
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05631321Medicaid
MS07384811Medicaid