Provider Demographics
NPI:1285012609
Name:PADGETT, MAVERICK RAY
Entity Type:Individual
Prefix:
First Name:MAVERICK
Middle Name:RAY
Last Name:PADGETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 W SHADY LN
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-4005
Mailing Address - Country:US
Mailing Address - Phone:580-279-8873
Mailing Address - Fax:
Practice Address - Street 1:1410 S GIN RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-7348
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health