Provider Demographics
NPI:1063975324
Name:LUBBERS, MELISSA S
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:S
Last Name:LUBBERS
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 1:714 S HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-3002
Mailing Address - Country:US
Mailing Address - Phone:316-295-4800
Mailing Address - Fax:316-295-4811
Practice Address - Street 1:714 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-3002
Practice Address - Country:US
Practice Address - Phone:316-295-4800
Practice Address - Fax:316-295-4811
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS002101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)