Provider Demographics
NPI:1679881361
Name:FOUSE, MICKI MELINDA
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:MELINDA
Last Name:FOUSE
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:RR 2 BOX 989
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-9761
Mailing Address - Country:US
Mailing Address - Phone:580-298-5062
Mailing Address - Fax:580-298-5072
Practice Address - Street 1:608 HIGHWAY 271 N
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2055
Practice Address - Country:US
Practice Address - Phone:580-298-5062
Practice Address - Fax:580-298-5072
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health