Provider Demographics
NPI:1275025405
Name:KOKENGE, MELISSA M
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:KOKENGE
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 1:625 COURT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1919
Mailing Address - Country:US
Mailing Address - Phone:712-252-3871
Mailing Address - Fax:877-728-4419
Practice Address - Street 1:625 COURT ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1919
Practice Address - Country:US
Practice Address - Phone:712-252-3871
Practice Address - Fax:877-728-4419
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10028582900Medicaid