Provider Demographics
NPI:1144624008
Name:OUTLAW, MELODY
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:OUTLAW
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 1:18001 HIGHLAND PARK RD
Mailing Address - Street 2:APT 407
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18001 HIGHLAND PARK RD
Practice Address - Street 2:APT 407
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-5001
Practice Address - Country:US
Practice Address - Phone:405-761-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty