Provider Demographics
NPI:1659320588
Name:PHILLIPS, MELANIE LEE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MRS
Other - First Name:MELANIE
Other - Middle Name:LEE
Other - Last Name:CANAVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:6 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1973
Mailing Address - Country:US
Mailing Address - Phone:816-313-2800
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:101 NW ENGLEWOOD RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-4063
Practice Address - Country:US
Practice Address - Phone:816-313-2800
Practice Address - Fax:816-792-9819
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017426237600000X
KS2000237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431857086OtherTAX ID #
MO34245019OtherBCBS
MOK35D818Medicare PIN
MO34245019OtherBCBS