Provider Demographics
NPI:1114275567
Name:CARRASCO, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:CARRASCO
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 1:3901 S WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1635
Mailing Address - Country:US
Mailing Address - Phone:918-872-8435
Mailing Address - Fax:
Practice Address - Street 1:11428 E 20TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6451
Practice Address - Country:US
Practice Address - Phone:845-321-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid