Provider Demographics
NPI:1124381835
Name:PERRY, ANDRIA NICOLE (BS,BHRS)
Entity Type:Individual
Prefix:MRS
First Name:ANDRIA
Middle Name:NICOLE
Last Name:PERRY
Suffix:
Gender:F
Credentials:BS,BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 KINGREY LN
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5723
Mailing Address - Country:US
Mailing Address - Phone:918-647-9808
Mailing Address - Fax:
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:580-371-3799
Practice Address - Fax:580-371-2056
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226970AMedicaid