Provider Demographics
NPI:1215371711
Name:RUCKER, LASHYDREA
Entity Type:Individual
Prefix:
First Name:LASHYDREA
Middle Name:
Last Name:RUCKER
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 1:3136 NW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6720
Mailing Address - Country:US
Mailing Address - Phone:405-651-4774
Mailing Address - Fax:
Practice Address - Street 1:3136 NW 34TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6720
Practice Address - Country:US
Practice Address - Phone:405-651-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid