Provider Demographics
NPI:1538838545
Name:BAKER RUSSO, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:BAKER RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 JOURNEY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6655
Mailing Address - Country:US
Mailing Address - Phone:337-212-5921
Mailing Address - Fax:
Practice Address - Street 1:1325 S MORGAN AVE
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-5121
Practice Address - Country:US
Practice Address - Phone:337-521-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6925235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist