Provider Demographics
NPI:1447849302
Name:DODGION, MECHELLE RENEE (PTA)
Entity type:Individual
Prefix:
First Name:MECHELLE
Middle Name:RENEE
Last Name:DODGION
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12464 S 417TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-8756
Mailing Address - Country:US
Mailing Address - Phone:918-638-7211
Mailing Address - Fax:
Practice Address - Street 1:6715 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-4520
Practice Address - Country:US
Practice Address - Phone:918-806-0106
Practice Address - Fax:918-806-0113
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKTA250225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKTA250Medicaid