Provider Demographics
NPI:1063876498
Name:WILSON, MELISSA ANN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:BURTLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2511 BRAXTON DR
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-8008
Mailing Address - Country:US
Mailing Address - Phone:580-334-5647
Mailing Address - Fax:
Practice Address - Street 1:202639 E COUNTY ROAD 42
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-5442
Practice Address - Country:US
Practice Address - Phone:580-254-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker