Provider Demographics
NPI:1457854952
Name:KING, MELISSA GAYLE (MA-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GAYLE
Last Name:KING
Suffix:
Gender:F
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1718
Mailing Address - Country:US
Mailing Address - Phone:606-388-4511
Mailing Address - Fax:
Practice Address - Street 1:1451 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1718
Practice Address - Country:US
Practice Address - Phone:606-388-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist