Provider Demographics
NPI:1659404093
Name:BROOKSHIRE, MELISSA (SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BROOKSHIRE
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 1:11030 RAVEN RIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8512
Mailing Address - Country:US
Mailing Address - Phone:919-844-6611
Mailing Address - Fax:
Practice Address - Street 1:11030 RAVEN RIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8512
Practice Address - Country:US
Practice Address - Phone:919-844-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5210235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411976Medicaid