Provider Demographics
NPI:1942772710
Name:MELIS, MARC (SLPA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:MELIS
Suffix:
Gender:M
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 S BALA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2911
Mailing Address - Country:US
Mailing Address - Phone:480-299-3975
Mailing Address - Fax:
Practice Address - Street 1:2529 S BALA DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2911
Practice Address - Country:US
Practice Address - Phone:480-299-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ115752355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11575Medicaid