Provider Demographics
NPI:1083753941
Name:BASEL, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BASEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BRUZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 BALCHEN ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1111
Mailing Address - Country:US
Mailing Address - Phone:516-804-5409
Mailing Address - Fax:
Practice Address - Street 1:306 BALCHEN ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1111
Practice Address - Country:US
Practice Address - Phone:516-804-5409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist