1487925335 NPI number — SANDRA L. REESE-KECK BCBA, LPC

Table of content: SANDRA L. REESE-KECK BCBA, LPC (NPI 1487925335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487925335 NPI number — SANDRA L. REESE-KECK BCBA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REESE-KECK
Provider First Name:
SANDRA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487925335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
729 OVERLAND TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-540-4163
Provider Business Mailing Address Fax Number:
580-294-5204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
729 OVERLAND TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-540-4163
Provider Business Practice Location Address Fax Number:
580-294-5204
Provider Enumeration Date:
01/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  6531 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 1-11-9464 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200480230C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6531 . This is a "OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200868590A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1-11-9464 . This is a "BEHAVIOR ANALYST CERTIFICATION BOARD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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