Basic Information
| Provider Information | |||||||||
| NPI: | 1659320588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANAVAN | ||||||||
| OtherFirstName: | MELANIE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AUD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640681973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163132800 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 NW ENGLEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641184063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163132800 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 2004017426 | MO | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237600000X | 2000 | KS | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 431857086 | 01 | MO | TAX ID # | OTHER | 34245019 | 01 | MO | BCBS | OTHER |