Basic Information
| Provider Information | |||||||||
| NPI: | 1447971676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEFNER | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 523 S FANNIN AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
| FaxNumber: | 9035860001 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 E COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757664910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
| FaxNumber: | 9035860001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 72279 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.