Provider Demographics
NPI:1255655627
Name:BUYSKE, MELISSA JEAN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:BUYSKE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:JEAN
Other - Last Name:BUYSKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:2915 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4820235Z00000X
WALL60137807235Z00000X
AZSLP8176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ786574Medicaid