MEDICARE: MELANA IVIE

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	171M00000X	Case Manager/Care Coordinator
2	101YP2500X	Professional Counselor	10251	OK
3	101YM0800X	Mental Health Counselor	10251	OK

General Provider Information

NPI Number	:	1285154377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELANA IVIE

Provider Business Mailing Address
First Line	:	4416 W HOUSTON ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4645
Country	:	US
Telephone Number	:	918-728-4760
Fax Number	:

Provider Business Practice Location Address
First Line	:	4416 W HOUSTON ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4645
Country	:	US
Telephone Number	:	918-288-0027
Fax Number	:

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

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	08/23/2024

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Directions to “ MELANA IVIE ” Practice Location

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