Provider Demographics
NPI:1225766959
Name:WILSON, MELANIE ELAINE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ELAINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19200 SPACE CENTER BLVD APT 315
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3436
Practice Address - Country:US
Practice Address - Phone:281-284-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist