Provider Demographics
NPI:1205271731
Name:SIDOR, MELINDA (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:SIDOR
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 22ND ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4106
Mailing Address - Country:US
Mailing Address - Phone:253-691-6813
Mailing Address - Fax:
Practice Address - Street 1:3508 22ND ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-4106
Practice Address - Country:US
Practice Address - Phone:253-691-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60339577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist