Provider Demographics
NPI:1710376421
Name:PITTS JOHNSON, MELISSA (MS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PITTS JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 MAHANEY AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5795
Mailing Address - Country:US
Mailing Address - Phone:918-901-9300
Mailing Address - Fax:
Practice Address - Street 1:2021 MAHANEY AVE STE 4
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5795
Practice Address - Country:US
Practice Address - Phone:918-901-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional