Provider Demographics
NPI:1043506165
Name:MERTZ, MELISSA LYNN
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LYNN
Last Name:MERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 WHITE TAIL DR
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-7809
Mailing Address - Country:US
Mailing Address - Phone:405-568-1831
Mailing Address - Fax:
Practice Address - Street 1:602 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200381940BMedicaid