Provider Demographics
NPI:1821636770
Name:MARTIN, MELISSA (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:MARTIN
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 1:3425 BANNERMAN RD STE 105
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-7063
Mailing Address - Country:US
Mailing Address - Phone:813-493-1116
Mailing Address - Fax:
Practice Address - Street 1:1132 GREENSWARD DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-6775
Practice Address - Country:US
Practice Address - Phone:813-493-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist