Provider Demographics
NPI:1043798721
Name:FORAKER, MICAH DELENE
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:DELENE
Last Name:FORAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278871 E 1840 RD
Mailing Address - Street 2:
Mailing Address - City:COMANCHE
Mailing Address - State:OK
Mailing Address - Zip Code:73529-4042
Mailing Address - Country:US
Mailing Address - Phone:580-467-3173
Mailing Address - Fax:
Practice Address - Street 1:278871 E 1840 RD
Practice Address - Street 2:
Practice Address - City:COMANCHE
Practice Address - State:OK
Practice Address - Zip Code:73529-4042
Practice Address - Country:US
Practice Address - Phone:580-467-3173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health