Provider Demographics
NPI:1235373465
Name:BOULWARE, SANDRA SUE DALE (LPC, MAC)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:SUE DALE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:LPC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 K ST NW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2915
Mailing Address - Country:US
Mailing Address - Phone:918-542-5671
Mailing Address - Fax:
Practice Address - Street 1:1121 K ST NW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-2915
Practice Address - Country:US
Practice Address - Phone:918-542-5671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK440101Y00000X, 101YP2500X
OK15991101YP2500X
OK109413101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool