Provider Demographics
NPI:1407911126
Name:MELLSTROM, BETHANY PIERCE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:PIERCE
Last Name:MELLSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481A WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2643
Mailing Address - Country:US
Mailing Address - Phone:413-522-2174
Mailing Address - Fax:
Practice Address - Street 1:111 S BEDFORD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5145
Practice Address - Country:US
Practice Address - Phone:781-272-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6059235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist