Provider Demographics
NPI:1063603611
Name:MIHALICH, MELINDA ALEXANDRIA (CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ALEXANDRIA
Last Name:MIHALICH
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:MS
Other - First Name:MELINDA
Other - Middle Name:ALEXANDRIA
Other - Last Name:GAITHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60543
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99706
Mailing Address - Country:US
Mailing Address - Phone:907-474-9705
Mailing Address - Fax:
Practice Address - Street 1:1327 KALAKAKET STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-452-4517
Practice Address - Fax:907-452-4263
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK230235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A021OtherTRICARE
AKSP4171Medicaid