Provider Demographics
NPI:1215563697
Name:RADA, SUSAN ELISE (BCABA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELISE
Last Name:RADA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 E 2ND ST APT 4006
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6385
Mailing Address - Country:US
Mailing Address - Phone:405-503-0863
Mailing Address - Fax:
Practice Address - Street 1:5100 N BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3623
Practice Address - Country:US
Practice Address - Phone:405-503-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0188836103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty