Provider Demographics
NPI:1801222880
Name:CASE-VINCENT, MELISSA ANN (PSYD, LSSP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:CASE-VINCENT
Suffix:
Gender:F
Credentials:PSYD, LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 W WILLIAM CANNON DR STE B103
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1978
Mailing Address - Country:US
Mailing Address - Phone:512-891-1500
Mailing Address - Fax:
Practice Address - Street 1:6012 W WILLIAM CANNON DR STE B103
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1978
Practice Address - Country:US
Practice Address - Phone:512-891-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36551103TC0700X
TX70023103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool