Provider Demographics
NPI:1528748993
Name:MELLES, ELIZABETH A (PHD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:MELLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W KEETOOWAH ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3824
Mailing Address - Country:US
Mailing Address - Phone:918-708-9558
Mailing Address - Fax:918-708-9580
Practice Address - Street 1:310 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3824
Practice Address - Country:US
Practice Address - Phone:918-708-9558
Practice Address - Fax:918-708-9580
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical