Basic Information
| Provider Information | |||||||||
| NPI: | 1679667398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHELDON | ||||||||
| FirstName: | MELODY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MA., CCC-SP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 N. SECOND | ||||||||
| Address2: | STE C | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675221 | ||||||||
| FaxNumber: | 5412675221 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 N. SECOND | ||||||||
| Address2: | STE C | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675221 | ||||||||
| FaxNumber: | 5412675221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 10886 | OR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 7002 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 089037 | 05 | OR | MEDICAID | 047063 | 05 | OR | MEDICAID |