Provider Demographics
NPI:1164053138
Name:MAZZAGLIA, MELISSA (SLP-CF)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MAZZAGLIA
Suffix:
Gender:F
Credentials:SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 W CAYUSE CREEK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6135
Mailing Address - Country:US
Mailing Address - Phone:208-996-0552
Mailing Address - Fax:208-914-6597
Practice Address - Street 1:1508 W CAYUSE CREEK DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6135
Practice Address - Country:US
Practice Address - Phone:208-996-0552
Practice Address - Fax:208-914-6597
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4219235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790200202Medicaid
IDTSLP-4219Medicaid