Healthcare Provider Details

I. General information

NPI: 1437399839
Provider Name (Legal Business Name): MELISSA A. LIEVANO-GOMES M.S. SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 6TH ST NW
WINTER HAVEN FL
33881-4013
US

IV. Provider business mailing address

2234 BLACK LAKE BLVD
WINTER GARDEN FL
34787-4658
US

V. Phone/Fax

Practice location:
  • Phone: 863-229-8319
  • Fax: 863-229-8492
Mailing address:
  • Phone: 407-654-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ4555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: