MEDICARE: MRS. MELISSA WISAN EDRICH M.S. 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
1	235Z00000X	Speech-Language Pathologist	SA 4416	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538271911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA WISAN EDRICH M.S. CCC/SLP

Provider Business Mailing Address
First Line	:	PO BOX 290370
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33329-0370
Country	:	US
Telephone Number	:	954-262-4346
Fax Number	:	954-262-2269

Provider Business Practice Location Address
First Line	:	6100 GRIFFIN RD
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33314-4416
Country	:	US
Telephone Number	:	954-262-7782
Fax Number	:	954-262-2847

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	01/27/2016

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Directions to “ MRS. MELISSA WISAN EDRICH M.S. CCC/SLP” Practice Location

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