Provider Demographics
NPI:1134527617
Name:WITHROW, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:WITHROW
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 1:4811 S JACKSON AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-8101
Mailing Address - Country:US
Mailing Address - Phone:918-280-9104
Mailing Address - Fax:918-609-2850
Practice Address - Street 1:514 W ATLANTA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7004
Practice Address - Country:US
Practice Address - Phone:918-280-9104
Practice Address - Fax:918-609-2850
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator