Basic Information
| Provider Information | |||||||||
| NPI: | 1962914002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLINTON | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLINTON | ||||||||
| OtherFirstName: | MELINDA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 903 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184596795 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 ALEXANDER ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712512001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184596795 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 7224 | OK | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 7224 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200323940 | 05 | OK | MEDICAID |