Provider Demographics
NPI:1144391319
Name:MELLO, STEPHANIE L (MA CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:MELLO
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 LEGACY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115
Mailing Address - Country:US
Mailing Address - Phone:678-492-0400
Mailing Address - Fax:
Practice Address - Street 1:124 HAMMOND DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6558
Practice Address - Country:US
Practice Address - Phone:678-492-0400
Practice Address - Fax:678-493-2052
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA693050591DMedicaid