Healthcare Provider Details

I. General information

NPI: 1528484714
Provider Name (Legal Business Name): MELISSA MITCHELL M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PASEO DE LOS LAURELES 404 1205
MEXICO CITY MEXICO
05100
MX

IV. Provider business mailing address

PO BOX 9000
BROWNSVILLE TX
78520-0900
US

V. Phone/Fax

Practice location:
  • Phone: 555-259-4878
  • Fax:
Mailing address:
  • Phone: 555-259-4878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2203000201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: