Provider Demographics
NPI:1558035170
Name:WILSON, MELODY DIXON
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:DIXON
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 1:3808 GERALD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-4420
Mailing Address - Country:US
Mailing Address - Phone:281-382-4451
Mailing Address - Fax:
Practice Address - Street 1:2911 CAMERON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3713
Practice Address - Country:US
Practice Address - Phone:318-651-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator