Provider Demographics
NPI:1942841937
Name:DURST, MELISSA JANE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:DURST
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JANE
Other - Last Name:SANDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:N8892 COUNTY ROAD J
Mailing Address - Street 2:
Mailing Address - City:BLANCHARDVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53516-9641
Mailing Address - Country:US
Mailing Address - Phone:608-279-0534
Mailing Address - Fax:
Practice Address - Street 1:N8892 COUNTY ROAD J
Practice Address - Street 2:
Practice Address - City:BLANCHARDVILLE
Practice Address - State:WI
Practice Address - Zip Code:53516-9641
Practice Address - Country:US
Practice Address - Phone:608-279-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019031614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist