Provider Demographics
NPI:1306210927
Name:MILLER, MELISSA (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 N VIRGINIA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3519
Mailing Address - Country:US
Mailing Address - Phone:770-377-0999
Mailing Address - Fax:
Practice Address - Street 1:1777 NORTHEAST EXPY NE STE 120
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2480
Practice Address - Country:US
Practice Address - Phone:404-228-8558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009620235Z00000X
GAPCET002286235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003195547BMedicaid