Provider Demographics
NPI:1922122449
Name:CLARK-MEDYESY, MELANIE BETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:BETH
Last Name:CLARK-MEDYESY
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 1:176 CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1720
Mailing Address - Country:US
Mailing Address - Phone:401-331-1274
Mailing Address - Fax:
Practice Address - Street 1:176 CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1720
Practice Address - Country:US
Practice Address - Phone:401-331-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist