Provider Demographics
NPI:1659590099
Name:GENTNER, MELISSA DAWN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:DAWN
Last Name:GENTNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:DAWN
Other - Last Name:BOERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1735 BLUE COURSE DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4322
Mailing Address - Country:US
Mailing Address - Phone:814-404-6318
Mailing Address - Fax:
Practice Address - Street 1:3054 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2755
Practice Address - Country:US
Practice Address - Phone:814-234-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008509235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL008509OtherSTATE LICENSE NUMBER
PA1016574980001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER