Provider Demographics
NPI:1164709507
Name:NORTHCUTT, CASEY L (BHRS)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:L
Last Name:NORTHCUTT
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12619 COUNTY ROAD 3520
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1711
Mailing Address - Country:US
Mailing Address - Phone:580-320-5657
Mailing Address - Fax:
Practice Address - Street 1:121 E MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DAVIS
Practice Address - State:OK
Practice Address - Zip Code:73030-1973
Practice Address - Country:US
Practice Address - Phone:580-369-5080
Practice Address - Fax:580-369-2488
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid