Provider Demographics
NPI:1821112269
Name:BALTHAZOR, MELISSA (SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHISHOLM TRAIL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-2506
Mailing Address - Country:US
Mailing Address - Phone:512-341-9991
Mailing Address - Fax:512-341-0019
Practice Address - Street 1:12 CHISHOLM TRAIL RD STE 100
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-2506
Practice Address - Country:US
Practice Address - Phone:512-341-9991
Practice Address - Fax:512-341-0019
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5728103K00000X
TX103115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186959604Medicaid
TX1869596-04Medicaid
TX186959603Medicaid