Basic Information
| Provider Information | |||||||||
| NPI: | 1588940365 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | BHRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21064 STATE ROAD 78 | ||||||||
| Address2: | |||||||||
| City: | CALERA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747304825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803803230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | 5809318022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200049040 | 05 | OK | MEDICAID |