Provider Demographics
NPI:1982167557
Name:STILWELL, MELISSA RENEE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:STILWELL
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 1:2138 D R BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-1436
Mailing Address - Country:US
Mailing Address - Phone:863-608-0050
Mailing Address - Fax:
Practice Address - Street 1:851 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6280
Practice Address - Country:US
Practice Address - Phone:813-661-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16501235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist