Provider Demographics
NPI:1043204399
Name:BOBO, MARY L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BOBO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 GREENBRIAR PL
Mailing Address - Street 2:STE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7645
Mailing Address - Country:US
Mailing Address - Phone:405-692-4000
Mailing Address - Fax:405-692-4001
Practice Address - Street 1:1625 GREENBRIAR PL
Practice Address - Street 2:STE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7645
Practice Address - Country:US
Practice Address - Phone:405-692-4000
Practice Address - Fax:405-692-4001
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2194101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health