Provider Demographics
NPI:1316551278
Name:MELISSA PETERS SPEECH PATHOLOGY INC
Entity Type:Organization
Organization Name:MELISSA PETERS SPEECH PATHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:REVA
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:424-279-8379
Mailing Address - Street 1:PO BOX 10102
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2728 3RD ST APT 203
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-4173
Practice Address - Country:US
Practice Address - Phone:424-279-8379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Multi-Specialty