Basic Information
| Provider Information | |||||||||
| NPI: | 1609160803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCC/SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VITALE | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC/SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 322 S BIRCHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402062632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133843 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 DUPONT CIRCLE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402174761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028930159 | ||||||||
| FaxNumber: | 5022133843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2011 | ||||||||
| LastUpdateDate: | 06/06/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2355 | KY | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 22005277A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.