Provider Demographics
NPI:1881412013
Name:FORNOFF, MELISSA ANN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:FORNOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28614 BULL RING
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS RANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78015-4351
Mailing Address - Country:US
Mailing Address - Phone:815-218-6100
Mailing Address - Fax:
Practice Address - Street 1:28604 INTERSTATE 10 W
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-9142
Practice Address - Country:US
Practice Address - Phone:830-755-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist