Basic Information
| Provider Information | |||||||||
| NPI: | 1972556306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 N. MAIN | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | 3163837925 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 N WACO AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607550 | ||||||||
| FaxNumber: | 3163838241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 389928 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |