Provider Demographics
NPI:1225445471
Name:MOBLEY, DETRA
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:
Last Name:MOBLEY
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 1:3975 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-8213
Mailing Address - Country:US
Mailing Address - Phone:405-282-2176
Mailing Address - Fax:405-809-3552
Practice Address - Street 1:13101 S PENN AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4900
Practice Address - Country:US
Practice Address - Phone:405-809-3542
Practice Address - Fax:405-809-3552
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health