=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306140389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA RANAE FOWLER MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2011
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5613 N OAKWOOD RD
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73703-9345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-548-6808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 LAKE TRAIL DR
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-6845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-747-2163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 4688
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------