Healthcare Provider Details

I. General information

NPI: 1790502342
Provider Name (Legal Business Name): MELISSA WALLAIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 S MINGO RD STE 101
TULSA OK
74133-5721
US

IV. Provider business mailing address

9228 S MINGO RD STE 101
TULSA OK
74133-5721
US

V. Phone/Fax

Practice location:
  • Phone: 405-378-2727
  • Fax: 405-378-2776
Mailing address:
  • Phone: 405-378-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12398
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: