Provider Demographics
NPI:1467571547
Name:LARSON, MELISSA (ST)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2079
Mailing Address - Country:US
Mailing Address - Phone:309-693-9189
Mailing Address - Fax:309-693-9946
Practice Address - Street 1:7725 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2079
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:309-693-9946
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242-000239235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist