MEDICARE: DR. MELISSA JEAN LEEDY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY 7846	FL
2	103TH0100X	Health Service Psychologist	1268	OK

General Provider Information

NPI Number	:	1194962720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA JEAN LEEDY PHD

Provider Business Mailing Address
First Line	:	2035A WEST HOUSTON STREET
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-8792
Country	:	US
Telephone Number	:	918-505-4367
Fax Number	:	888-371-9410

Provider Business Practice Location Address
First Line	:	2035A WEST HOUSTON STREET
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-8792
Country	:	US
Telephone Number	:	918-505-4367
Fax Number	:	888-371-9410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	09/02/2022

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