Provider Demographics
NPI:1720386766
Name:PETERSSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PETERSSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6007
Mailing Address - Country:US
Mailing Address - Phone:201-410-7897
Mailing Address - Fax:
Practice Address - Street 1:625 W RIDGE PIKE
Practice Address - Street 2:BUILDING C SUITE 105
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1180
Practice Address - Country:US
Practice Address - Phone:610-834-4099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist