Provider Demographics
NPI:1831511625
Name:BIDLACK, MELISSA A (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:A
Last Name:BIDLACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:RAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6569 N CHARLES ST
Mailing Address - Street 2:PHYSICIANS PAVILION WEST, SUITE 401
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6831
Mailing Address - Country:US
Mailing Address - Phone:443-849-2087
Mailing Address - Fax:
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:PHYSICIANS PAVILION WEST, SUITE 401
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:443-849-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist