Provider Demographics
NPI:1144570151
Name:POWELL, SUSAN (MED)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42012 TIMBER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOWE
Mailing Address - State:OK
Mailing Address - Zip Code:74940-3612
Mailing Address - Country:US
Mailing Address - Phone:918-653-3135
Mailing Address - Fax:918-647-2181
Practice Address - Street 1:42012 TIMBER RIDGE RD
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:OK
Practice Address - Zip Code:74940-3612
Practice Address - Country:US
Practice Address - Phone:918-653-3135
Practice Address - Fax:918-647-2181
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20226970Medicaid