Healthcare Provider Details

I. General information

NPI: 1316551278
Provider Name (Legal Business Name): MELISSA PETERS SPEECH PATHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 3RD ST APT 203
SANTA MONICA CA
90405-4173
US

IV. Provider business mailing address

PO BOX 10102
MARINA DEL REY CA
90295-6102
US

V. Phone/Fax

Practice location:
  • Phone: 424-279-8379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA REVA PETERS
Title or Position: DIRECTOR
Credential: SLP
Phone: 424-279-8379