Provider Demographics
NPI:1699266643
Name:DE LA O, MELISSA ANNE (AUD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANNE
Last Name:DE LA O
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD # 1B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-812-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8159231H00000X
231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2478877Medicaid