Basic Information
| Provider Information | |||||||||
| NPI: | 1093371304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCCI | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21758 54TH AVE | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113641415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3478692557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15050 14TH RD | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113572609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670071 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 10/13/2020 | ||||||||
| NPIReactivationDate: | 10/28/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 235Z00000X | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.