Provider Demographics
NPI:1235167057
Name:ANDERSON, MARY PEARSON (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PEARSON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MICKI
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:4045 NW 64TH ST STE 520
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-8608
Mailing Address - Country:US
Mailing Address - Phone:405-842-4911
Mailing Address - Fax:877-777-2249
Practice Address - Street 1:4045 NW 64TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1684
Practice Address - Country:US
Practice Address - Phone:405-842-4911
Practice Address - Fax:405-842-5807
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA105489Medicare UPIN
OK245-515702Medicare PIN