Provider Demographics
NPI:1598899759
Name:BOLTZ, MELISSA ANN (ST)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:BOLTZ
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 STONEHURST CT
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-5939
Mailing Address - Country:US
Mailing Address - Phone:773-304-6009
Mailing Address - Fax:
Practice Address - Street 1:2011 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5945
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008101235Z00000X
TX111577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103034Medicaid
IL103034Medicaid