Provider Demographics
NPI:1114353661
Name:LUNDE, RAQUEL R
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:R
Last Name:LUNDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:MERRIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS
Mailing Address - Street 1:5105 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-2707
Mailing Address - Country:US
Mailing Address - Phone:903-328-8087
Mailing Address - Fax:
Practice Address - Street 1:2020 N COUNCIL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-1142
Practice Address - Country:US
Practice Address - Phone:903-328-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27-0255792101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200489380AMedicaid