Provider Demographics
NPI:1467210492
Name:MELANCON, MICHAEL SHANE JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:MELANCON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 BLUEBONNET BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-408-7995
Mailing Address - Fax:225-408-7997
Practice Address - Street 1:4920 CHURCH STREET
Practice Address - Street 2:SUITE E
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791
Practice Address - Country:US
Practice Address - Phone:225-570-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA340669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist