Provider Demographics
NPI:1881629319
Name:WISE, MELISSA LYNN (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNN
Last Name:WISE
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:LYNN
Other - Last Name:SONKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 W HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-302-0833
Mailing Address - Fax:847-438-9141
Practice Address - Street 1:122 W HARBOR DR
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-302-0833
Practice Address - Fax:847-438-9141
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5632106OtherBLUECROSS BLUESHIELD
IL9387565OtherPRIVATE HEALTH CARE SYSTE