Basic Information
| Provider Information | |||||||||
| NPI: | 1255688628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3726 SE 132ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972363318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037607073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12441 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032557040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2012 | ||||||||
| LastUpdateDate: | 08/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 11322 | OR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.