Provider Demographics
NPI:1396254629
Name:MELLON, LAUREN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MELLON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 E 7TH ST APT 109
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3034
Mailing Address - Country:US
Mailing Address - Phone:704-692-5424
Mailing Address - Fax:
Practice Address - Street 1:6124 FALCON LANE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101
Practice Address - Country:US
Practice Address - Phone:573-634-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170318235Z00000X
MA229644235Z00000X
MTSLP-SP-LIC-6639235Z00000X
NC11893235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist