Provider Demographics
NPI:1760403034
Name:BOLDIZAR, MELISSA LYNN (SP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNN
Last Name:BOLDIZAR
Suffix:
Gender:F
Credentials:SP
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:MILANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ST
Mailing Address - Street 1:406 EAST ST
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-1429
Mailing Address - Country:US
Mailing Address - Phone:330-868-4332
Mailing Address - Fax:
Practice Address - Street 1:406 EAST ST
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-1429
Practice Address - Country:US
Practice Address - Phone:330-868-4332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 5937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000134720OtherANTHEM BC/BS