Provider Demographics
NPI:1033423389
Name:MELLENCAMP, KEVIN ERNEST (MS LPC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ERNEST
Last Name:MELLENCAMP
Suffix:
Gender:M
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 NW HOMESTEAD DR STE G
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5243
Mailing Address - Country:US
Mailing Address - Phone:580-355-8883
Mailing Address - Fax:580-355-8885
Practice Address - Street 1:1320 NW HOMESTEAD DR STE G
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5243
Practice Address - Country:US
Practice Address - Phone:580-355-8883
Practice Address - Fax:580-355-8885
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4005101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor