Provider Demographics
NPI:1376980243
Name:BALDWIN, MELISSA A
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BALDWIN
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:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:RATTAN
Mailing Address - State:OK
Mailing Address - Zip Code:74562-0171
Mailing Address - Country:US
Mailing Address - Phone:580-271-0923
Mailing Address - Fax:
Practice Address - Street 1:6202 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1099
Practice Address - Country:US
Practice Address - Phone:845-321-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid