Provider Demographics
NPI:1710207154
Name:WILDES, MELISSA NOEL (MASTERS OF SCIENCE)
Entity Type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:NOEL
Last Name:WILDES
Suffix:
Gender:F
Credentials:MASTERS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 80TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2619
Mailing Address - Country:US
Mailing Address - Phone:646-533-5733
Mailing Address - Fax:
Practice Address - Street 1:1069 80TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2619
Practice Address - Country:US
Practice Address - Phone:646-533-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019872-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist