1417244179 NPI number — MELINDA SHAVER, PSY.D.

Table of content: (NPI 1417244179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417244179 NPI number — MELINDA SHAVER, PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELINDA SHAVER, PSY.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417244179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16460 N WOODLAND HILLS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HULBERT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74441-2247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-457-8100
Provider Business Mailing Address Fax Number:
918-453-1171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 N COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-457-8100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SHAVER
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
918-457-8100

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  103TC0700X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1427061209 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200092020A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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