Provider Demographics
NPI:1376817031
Name:BLACKBURN, MELISSA SUE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:SUE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:DEWBRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-3614
Practice Address - Street 1:610 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3245
Practice Address - Country:US
Practice Address - Phone:580-371-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPC05238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health