Basic Information
| Provider Information | |||||||||
| NPI: | 1497920052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLETTE | ||||||||
| FirstName: | SHERYL | ||||||||
| MiddleName: | EILEEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTY | ||||||||
| OtherFirstName: | SHERYL | ||||||||
| OtherMiddleName: | EILEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3705 MEDICAL PKWY | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124540392 | ||||||||
| FaxNumber: | 5124541233 | ||||||||
| Practice Location | |||||||||
| Address1: | 3705 MEDICAL PKWY | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124540392 | ||||||||
| FaxNumber: | 5124541233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 50828 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 80777A | 01 | TX | BCBS-HCAENT | OTHER | 80776A | 01 | TX | BCBS-AENTC | OTHER |