Provider Demographics
NPI:1295394088
Name:MELLENCAMP, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MELLENCAMP
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 1:1500 CULLEN AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2529
Mailing Address - Country:US
Mailing Address - Phone:832-655-3754
Mailing Address - Fax:
Practice Address - Street 1:4402 WILLIAMS DR STE 115
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1388
Practice Address - Country:US
Practice Address - Phone:832-655-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114667235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist