Provider Demographics
NPI:1174823504
Name:REYNOLDS-GIBSON, MELANIE ELLA (MSCCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:ELLA
Last Name:REYNOLDS-GIBSON
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MACKENZIE LANE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07438-8893
Mailing Address - Country:US
Mailing Address - Phone:973-208-1967
Mailing Address - Fax:
Practice Address - Street 1:7 WOODSTOCK TRAIL
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07438-8893
Practice Address - Country:US
Practice Address - Phone:973-697-1825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS0350200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist