Provider Demographics
NPI:1639678162
Name:FRY, MELISSA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:FRY
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 1:2074 WHEATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5093
Mailing Address - Country:US
Mailing Address - Phone:708-289-6948
Mailing Address - Fax:
Practice Address - Street 1:1900 OXFORD WAY
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-7900
Practice Address - Country:US
Practice Address - Phone:815-577-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist