Provider Demographics
NPI:1558401646
Name:MELADY, LISA YOUNG (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:YOUNG
Last Name:MELADY
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 1:7036 N WALL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5152
Mailing Address - Country:US
Mailing Address - Phone:317-201-1103
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5104
Practice Address - Country:US
Practice Address - Phone:503-228-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12624235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WCKDKMedicare ID - Type Unspecified