Provider Demographics
NPI:1417244179
Name:MELINDA SHAVER, PSY.D.
Entity Type:Organization
Organization Name:MELINDA SHAVER, PSY.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:918-457-8100
Mailing Address - Street 1:16460 N WOODLAND HILLS LN
Mailing Address - Street 2:
Mailing Address - City:HULBERT
Mailing Address - State:OK
Mailing Address - Zip Code:74441-2247
Mailing Address - Country:US
Mailing Address - Phone:918-457-8100
Mailing Address - Fax:918-453-1171
Practice Address - Street 1:315 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2703
Practice Address - Country:US
Practice Address - Phone:918-457-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TC0700X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1427061209OtherINDIVIDUAL NPI
OK200092020AMedicaid
OK239713108Medicare PIN