Provider Demographics
NPI:1134430697
Name:MEDELLIN, CASSIE ELAINE (SLP)
Entity type:Individual
Prefix:MRS
First Name:CASSIE
Middle Name:ELAINE
Last Name:MEDELLIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:CASSIE
Other - Middle Name:ELAINE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-4797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-4797
Practice Address - Country:US
Practice Address - Phone:832-668-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113882235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1134430697Medicaid