Provider Demographics
NPI:1033861851
Name:THETFORD-HARVEY, MARY GRACE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:THETFORD-HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GRACE
Other - Last Name:THETFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4502 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:918-660-3130
Mailing Address - Fax:918-660-3132
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2536
Practice Address - Country:US
Practice Address - Phone:918-660-3130
Practice Address - Fax:918-660-3132
Is Sole Proprietor?:No
Enumeration Date:2022-01-23
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK39482390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program