Healthcare Provider Details

I. General information

NPI: 1104323427
Provider Name (Legal Business Name): MELISSA SUZANNE COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 N 31ST ST
CLINTON OK
73601-9116
US

IV. Provider business mailing address

926 N BRYAN ST
WEATHERFORD OK
73096-3606
US

V. Phone/Fax

Practice location:
  • Phone: 580-323-9705
  • Fax: 580-323-9375
Mailing address:
  • Phone: 580-330-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: