Provider Demographics
NPI:1275523094
Name:GILLMER, MELISSA JEAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:GILLMER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:COVERSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:784 BLANDING BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7724
Mailing Address - Country:US
Mailing Address - Phone:904-264-2636
Mailing Address - Fax:904-517-1621
Practice Address - Street 1:784 BLANDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7724
Practice Address - Country:US
Practice Address - Phone:904-264-2636
Practice Address - Fax:904-517-1621
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA8670235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891070700Medicaid