Provider Demographics
NPI:1134519812
Name:GASTON, MELISSA R
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:GASTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BULLARD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1054
Mailing Address - Country:US
Mailing Address - Phone:559-801-2626
Mailing Address - Fax:559-314-6166
Practice Address - Street 1:420 BULLARD AVE STE 104
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1054
Practice Address - Country:US
Practice Address - Phone:718-909-6267
Practice Address - Fax:559-314-6166
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist