Provider Demographics
NPI:1699223420
Name:GIPSON, MELISSA (SLP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GIPSON
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 1:1080 BILL BACOT RD
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-8458
Mailing Address - Country:US
Mailing Address - Phone:601-942-1127
Mailing Address - Fax:
Practice Address - Street 1:285 HOLMES PITTMAN RD
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-3166
Practice Address - Country:US
Practice Address - Phone:601-736-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS0644OtherMISSISSIPPI STATE HEALTH LICENSE