Provider Demographics
NPI:1669435863
Name:MIMIDIS HORWATT, MELISSA ANNE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:MIMIDIS HORWATT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W BROAD ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3340
Mailing Address - Country:US
Mailing Address - Phone:703-533-8819
Mailing Address - Fax:703-533-7723
Practice Address - Street 1:8270 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4530
Practice Address - Country:US
Practice Address - Phone:571-423-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA50-1216113235Z00000X
VA2202005366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA231365369OtherTAX IDENTIFICATION NUMBER