1538387410 NPI number — MRS. BRANDI D DETHEROW LCSW PROVISIONAL

Table of content: MRS. BRANDI D DETHEROW LCSW PROVISIONAL (NPI 1538387410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538387410 NPI number — MRS. BRANDI D DETHEROW LCSW PROVISIONAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETHEROW
Provider First Name:
BRANDI
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW PROVISIONAL
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:
1538387410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
832 W COMMERCIAL ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-607-3444
Provider Business Mailing Address Fax Number:
918-227-1125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 E DEWEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAPULPA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74066-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-227-2016
Provider Business Practice Location Address Fax Number:
918-227-1125
Provider Enumeration Date:
04/23/2007

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: 1041C0700X , with the licence number:  NONE , 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)





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