Provider Demographics
NPI:1154658672
Name:MEHLBERG, ELAINE MARIE (SLP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:MEHLBERG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19465 DEERFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1701
Mailing Address - Country:US
Mailing Address - Phone:703-858-7620
Mailing Address - Fax:
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1701
Practice Address - Country:US
Practice Address - Phone:703-858-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558304253Medicaid