Healthcare Provider Details

I. General information

NPI: 1699614123
Provider Name (Legal Business Name): CORTNEY GRACE MELLINGTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 MILITARY AVE
BAXTER SPRINGS KS
66713-1509
US

IV. Provider business mailing address

1141 MILITARY AVE
BAXTER SPRINGS KS
66713-1509
US

V. Phone/Fax

Practice location:
  • Phone: 620-330-9036
  • Fax: 620-206-2514
Mailing address:
  • Phone: 620-330-9036
  • Fax: 620-206-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: