Provider Demographics
NPI:1508108309
Name:MILLER, MELISA SHAUNTAYE
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:SHAUNTAYE
Last Name:MILLER
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 1:2500 THOMAS DR APT 321
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2266
Mailing Address - Country:US
Mailing Address - Phone:405-314-6630
Mailing Address - Fax:
Practice Address - Street 1:1410 S. GIN ROAD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid