Provider Demographics
NPI:1417218207
Name:HOLMES, MELINDA (LPC)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105
Mailing Address - Country:US
Mailing Address - Phone:918-832-7763
Mailing Address - Fax:918-292-8250
Practice Address - Street 1:5319 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-832-7763
Practice Address - Fax:918-292-8250
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 104100000X, 101Y00000X
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid