=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568950632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA NICOLE BOUVERIE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2018
-----------------------------------------------------
Last Update Date | 04/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13397 SW 131ST ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-5816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-306-2453
-----------------------------------------------------
Fax | 305-506-6768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10061 SW 147TH PL
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33196-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-348-3427
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SZ8265
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------