Provider Demographics
NPI:1447794011
Name:OTTO, MELISSA NICHOLE (PPS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICHOLE
Last Name:OTTO
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NICHOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2521 NW 115TH PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6901
Mailing Address - Country:US
Mailing Address - Phone:405-778-1691
Mailing Address - Fax:
Practice Address - Street 1:12000 N VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7581
Practice Address - Country:US
Practice Address - Phone:405-835-6757
Practice Address - Fax:405-213-1628
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1447794011101YP2500X
OK101YS0200X, 103TS0200X
CA101YS0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1235535352OtherNPI