Provider Demographics
NPI:1992048896
Name:THAYER, MELISA BETH (SLPS)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:BETH
Last Name:THAYER
Suffix:
Gender:F
Credentials:SLPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MILL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-6400
Mailing Address - Country:US
Mailing Address - Phone:260-338-1241
Mailing Address - Fax:260-338-1231
Practice Address - Street 1:808 MILL LAKE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-6400
Practice Address - Country:US
Practice Address - Phone:260-338-1241
Practice Address - Fax:260-338-1231
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004226A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist