Provider Demographics
NPI:1467546424
Name:POOLE, MELISSA K (SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:K
Last Name:POOLE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5642
Mailing Address - Country:US
Mailing Address - Phone:510-752-7148
Mailing Address - Fax:510-752-7836
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:510-752-7148
Practice Address - Fax:510-752-7836
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ614679Medicaid