Provider Demographics
NPI:1073765996
Name:LIGHT, MELISSA B (MSOM, TXLAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:B
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MSOM, TXLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78722-2007
Mailing Address - Country:US
Mailing Address - Phone:512-775-4057
Mailing Address - Fax:
Practice Address - Street 1:2502 MANOR RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78722-2007
Practice Address - Country:US
Practice Address - Phone:512-775-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00701171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist