Provider Demographics
NPI:1790332872
Name:BREEDEN, MELISSA JANE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:ULLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5209
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5209
Mailing Address - Country:US
Mailing Address - Phone:865-982-3400
Mailing Address - Fax:865-238-2034
Practice Address - Street 1:2030 CHILHOWEE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5285
Practice Address - Country:US
Practice Address - Phone:865-982-3400
Practice Address - Fax:865-238-2034
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4065235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ051558Medicaid
TN4065OtherBOARD OF COMMUNICATION DISORDERS AND SCIENCES