Provider Demographics
NPI:1700915337
Name:MCDARIS, MELISSA ANN (BA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MCDARIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 S.W. 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467
Mailing Address - Country:US
Mailing Address - Phone:918-698-7134
Mailing Address - Fax:918-485-1709
Practice Address - Street 1:706 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5515
Practice Address - Country:US
Practice Address - Phone:918-485-6206
Practice Address - Fax:918-485-1709
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5299101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200366010BMedicaid