Provider Demographics
NPI:1154539187
Name:SHADDOX, MELODY ROSE (LPC)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:ROSE
Last Name:SHADDOX
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6838 SPRING ROSE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2945
Mailing Address - Country:US
Mailing Address - Phone:210-347-7034
Mailing Address - Fax:
Practice Address - Street 1:6838 SPRING ROSE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2945
Practice Address - Country:US
Practice Address - Phone:210-347-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor