Provider Demographics
NPI:1114040656
Name:ROSENTHAL, MARY MICHELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MICHELLE
Last Name:ROSENTHAL
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 1:650 S PEORIA
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-4429
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:918-560-0137
Practice Address - Street 1:2325 S HARVARD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3300
Practice Address - Country:US
Practice Address - Phone:918-712-4301
Practice Address - Fax:918-749-7777
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical