Provider Demographics
NPI:1720203078
Name:DESMOND, MELANIE P (MA SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:P
Last Name:DESMOND
Suffix:
Gender:F
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 WOODLANDS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3217
Mailing Address - Country:US
Mailing Address - Phone:904-616-3455
Mailing Address - Fax:904-473-8933
Practice Address - Street 1:128 WOODLANDS CREEK DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3217
Practice Address - Country:US
Practice Address - Phone:904-616-3455
Practice Address - Fax:904-473-8933
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887469700Medicaid