Provider Demographics
NPI:1679915201
Name:PORE, MELISSA SUE (CCC/SLP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:PORE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHIPPENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16254-3906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21158 PAINT BLVD
Practice Address - Street 2:
Practice Address - City:SHIPPENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16254-4024
Practice Address - Country:US
Practice Address - Phone:814-227-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08367235Z00000X
OHSP.11826235Z00000X
NY025845-1235Z00000X
PASL010282235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist