Basic Information
| Provider Information | |||||||||
| NPI: | 1902036411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LBP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 E ASTER AVE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735427817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803351215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 602 SW 38TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802485780 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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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 | 101YP2500X | 0025 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 100747400B | 05 | OK | MEDICAID |