Provider Demographics
NPI:1841354685
Name:MCCALLUM, MELONIE (EDD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MELONIE
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:EDD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 WYONIA WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2479
Mailing Address - Country:US
Mailing Address - Phone:404-919-6594
Mailing Address - Fax:
Practice Address - Street 1:210 WYONIA WAY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2479
Practice Address - Country:US
Practice Address - Phone:404-919-6594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895914AMedicaid