Provider Demographics
NPI:1710477302
Name:WILSON, MELINA (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CRYSTAL RUN ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941
Mailing Address - Country:US
Mailing Address - Phone:845-692-4391
Mailing Address - Fax:845-692-4397
Practice Address - Street 1:7 VAN KEUREN AVE
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-6621
Practice Address - Country:US
Practice Address - Phone:845-313-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028805-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist