Provider Demographics
NPI:1063290633
Name:MELLICK, KAITLYN SHEA (CF-SLP)
Entity type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:SHEA
Last Name:MELLICK
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4115
Mailing Address - Country:US
Mailing Address - Phone:321-412-0051
Mailing Address - Fax:
Practice Address - Street 1:107 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2827
Practice Address - Country:US
Practice Address - Phone:321-338-2419
Practice Address - Fax:321-301-4278
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist