Provider Demographics
NPI:1659763514
Name:PETRUSHKO, MELANIE J (MS CCC-S-LP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:J
Last Name:PETRUSHKO
Suffix:
Gender:F
Credentials:MS CCC-S-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5085 PETERSBURG RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41080-9350
Mailing Address - Country:US
Mailing Address - Phone:859-586-0081
Mailing Address - Fax:
Practice Address - Street 1:3699 ALEXANDRIA PIKE STE D
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-1789
Practice Address - Country:US
Practice Address - Phone:859-572-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSLPLPA00210185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist