Provider Demographics
NPI:1194929893
Name:MORENO-MATHERLY, MELISSA CHRISTINA (MA CCC)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:CHRISTINA
Last Name:MORENO-MATHERLY
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 BRETT PL UNIT 25
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-5107
Mailing Address - Country:US
Mailing Address - Phone:310-833-1972
Mailing Address - Fax:310-684-5480
Practice Address - Street 1:1442 BRETT PL UNIT 25
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-5107
Practice Address - Country:US
Practice Address - Phone:310-833-1972
Practice Address - Fax:310-684-5480
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13538235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist