Provider Demographics
NPI:1407469794
Name:BANUELOS, MELISSA LYNN (MS, SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16432 CEDAR CREST DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6711
Mailing Address - Country:US
Mailing Address - Phone:727-259-9190
Mailing Address - Fax:
Practice Address - Street 1:4401 E COLONIAL DR STE 107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5200
Practice Address - Country:US
Practice Address - Phone:407-898-5060
Practice Address - Fax:407-898-5185
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9724235Z00000X
FLSA19834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist