Provider Demographics
NPI:1215174271
Name:HARYANTO, MELODY CAROL (MA, CCC/SLP ASDCS)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:CAROL
Last Name:HARYANTO
Suffix:
Gender:F
Credentials:MA, CCC/SLP ASDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 IMPERIA DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-8988
Mailing Address - Country:US
Mailing Address - Phone:281-616-3839
Mailing Address - Fax:346-299-5196
Practice Address - Street 1:2743 IMPERIA DR STE 103
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-8988
Practice Address - Country:US
Practice Address - Phone:281-616-3839
Practice Address - Fax:346-299-5196
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist