Provider Demographics
NPI:1043775125
Name:MCTIRE, MELISSA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MCTIRE
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 1:110 TRAVIS TRL
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:LA
Mailing Address - Zip Code:71417-5098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4515 EDDIE WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-3628
Practice Address - Country:US
Practice Address - Phone:318-442-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty