Basic Information
| Provider Information | |||||||||
| NPI: | 1669797924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A.-CCCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HATCHER | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LOU | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 156 S DOSSETT DRIVE | ||||||||
| Address2: | PO BOX 70643 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394584 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 S DOSSETT DRIVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394355 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1601000500 | MI | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 1820 | TN | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1820 | 01 | TN | STATE LICENSE | OTHER | 1601000500 | 01 | MI | STATE LICENSE | OTHER |