Provider Demographics
NPI:1841636552
Name:CONRAD-FORTMANN, MELISSA ANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:CONRAD-FORTMANN
Suffix:
Gender:
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 1:11000 HAZELNUT LN
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:MD
Mailing Address - Zip Code:21770-6066
Mailing Address - Country:US
Mailing Address - Phone:443-418-7530
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:877-787-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05376235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD05376OtherMD LICENSE NUMBER