Provider Demographics
NPI:1063655819
Name:MORTENSON, MELISSA LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:MORTENSON
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 1:16 ANDREW LANE
Mailing Address - Street 2:BOX 1295
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-1295
Mailing Address - Country:US
Mailing Address - Phone:318-512-1842
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6945
Practice Address - Country:US
Practice Address - Phone:318-512-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004113235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist