=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861706822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARY MELTON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2010
-----------------------------------------------------
Last Update Date | 08/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 S MAIN ST
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-7933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-612-5480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 S MAIN ST
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74074-7933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-612-5480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED COUNSELOR
-----------------------------------------------------
Name | MARY A MELTON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-612-5480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1832
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------