Provider Demographics
NPI:1841601374
Name:SELVIDGE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SELVIDGE
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:PO BOX 390364
Mailing Address - Street 2:
Mailing Address - City:DUSTIN
Mailing Address - State:OK
Mailing Address - Zip Code:74839-0364
Mailing Address - Country:US
Mailing Address - Phone:918-346-5672
Mailing Address - Fax:
Practice Address - Street 1:112 FEARS ST.
Practice Address - Street 2:
Practice Address - City:DUSTIN
Practice Address - State:OK
Practice Address - Zip Code:74839-0364
Practice Address - Country:US
Practice Address - Phone:918-346-5672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator