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NPI Code Detail

MEDICARE: MELISSA LYNN MORTENSON MS, CCC-SLP

MEDICARE: MELISSA LYNN MORTENSON MS, CCC-SLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist004113CT

General Provider Information

NPI Number : 1063655819
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELISSA LYNN MORTENSON MS, CCC-SLP
Provider Business Mailing Address
First Line : 16 ANDREW LANE
Second Line : BOX 1295
City : PINEDALE
State : WY
Zip : 82941-1295
Country : US
Telephone Number : 318-512-1842
Fax Number :
Provider Business Practice Location Address
First Line : 333 1ST ST N
Second Line : SUITE 200
City : JACKSONVILLE BEACH
State : FL
Zip : 32250-6945
Country : US
Telephone Number : 318-512-1842
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2009
Last Update Date : 04/09/2009

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