=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114158482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE RAE GONZALEZ M.S.CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2009
-----------------------------------------------------
Last Update Date | 08/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2007 W. 3 MILE LINE SUITE 7
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-424-7555
-----------------------------------------------------
Fax | 956-424-7805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2007 W. 3 MILE LINE SUITE 7
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-424-7555
-----------------------------------------------------
Fax | 956-424-7805
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 104364
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------