Provider Demographics
NPI:1699045476
Name:RUSSELL, MELISSA LANE (AUD)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1534 PALMER VW
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-7218
Mailing Address - Country:US
Mailing Address - Phone:334-391-7638
Mailing Address - Fax:334-391-7638
Practice Address - Street 1:502 MADISON OAK DR
Practice Address - Street 2:SUITE 140
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4084
Practice Address - Country:US
Practice Address - Phone:210-647-3838
Practice Address - Fax:210-403-3166
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80129231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare PIN