Provider Demographics
NPI:1427061209
Name:SHAVER, MELINDA ANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:ANNE
Last Name:SHAVER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 BIRDIE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-1548
Mailing Address - Country:US
Mailing Address - Phone:620-926-1286
Mailing Address - Fax:620-577-2074
Practice Address - Street 1:201 N PENN AVE
Practice Address - Street 2:SUITE 507
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3357
Practice Address - Country:US
Practice Address - Phone:620-926-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK962103TC0700X
KS2326103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201124310Medicaid