Provider Demographics
NPI:1215977418
Name:MILES, MELISSA ANNE (MSCCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANNE
Last Name:MILES
Suffix:
Gender:F
Credentials:MSCCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 BRIGHTWAY DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-5569
Mailing Address - Country:US
Mailing Address - Phone:609-410-4725
Mailing Address - Fax:
Practice Address - Street 1:103 N 12TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2310
Practice Address - Country:US
Practice Address - Phone:609-410-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00307500235Z00000X
VA2202008963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1356644827OtherTYPE 2
NJ196764OtherPTAN