Provider Demographics
NPI:1104310770
Name:WEIDEL, MELISSA (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:
Last Name:WEIDEL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 TAYLOR DR APT 12
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6338
Mailing Address - Country:US
Mailing Address - Phone:814-571-8360
Mailing Address - Fax:
Practice Address - Street 1:803 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664
Practice Address - Country:US
Practice Address - Phone:540-459-5676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty