Provider Demographics
NPI:1104223395
Name:MELANIE DESMOND
Entity Type:Organization
Organization Name:MELANIE DESMOND
Other - Org Name:BEACHES SPEECH THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-616-3455
Mailing Address - Street 1:128 WOODLANDS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3217
Mailing Address - Country:US
Mailing Address - Phone:904-616-3455
Mailing Address - Fax:
Practice Address - Street 1:128 WOODLANDS CREEK DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3217
Practice Address - Country:US
Practice Address - Phone:904-616-3455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 235Z00000X
FLSA6650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014138500Medicaid