Provider Demographics
NPI:1245756857
Name:CASTLEBERRY, RANDA
Entity Type:Individual
Prefix:
First Name:RANDA
Middle Name:
Last Name:CASTLEBERRY
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 1:1318 S RIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-7078
Mailing Address - Country:US
Mailing Address - Phone:405-714-3091
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR # 190
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-3876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer