Provider Demographics
NPI:1639655319
Name:LARSON, MELISSA ANN (MS SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 W GLENOAKS BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2871
Mailing Address - Country:US
Mailing Address - Phone:626-222-9229
Mailing Address - Fax:
Practice Address - Street 1:147 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3407
Practice Address - Country:US
Practice Address - Phone:626-355-1729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist