Provider Demographics
NPI:1629471537
Name:FORKER, MELISSA ANN
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:FORKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 N. WHITTAKER ST.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117
Mailing Address - Country:US
Mailing Address - Phone:269-235-9821
Mailing Address - Fax:269-586-2336
Practice Address - Street 1:45 N. WHITTAKER ST.
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117
Practice Address - Country:US
Practice Address - Phone:269-235-9821
Practice Address - Fax:269-586-2336
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist