Provider Demographics
NPI:1134104664
Name:SURKA, MELISSA CLARK (MSP CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CLARK
Last Name:SURKA
Suffix:
Gender:F
Credentials:MSP CCC-SLP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSP CCC-SLP
Mailing Address - Street 1:5 EDGEVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-4847
Mailing Address - Country:US
Mailing Address - Phone:864-346-7751
Mailing Address - Fax:
Practice Address - Street 1:5 EDGEVIEW TRL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4847
Practice Address - Country:US
Practice Address - Phone:864-346-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3562235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0676Medicaid