Provider Demographics
NPI:1316576614
Name:RHODES, CORY AUSTIN
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:AUSTIN
Last Name:RHODES
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 1:3838 NW 36TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2916
Mailing Address - Country:US
Mailing Address - Phone:405-702-9032
Mailing Address - Fax:
Practice Address - Street 1:3838 NW 36TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2916
Practice Address - Country:US
Practice Address - Phone:405-702-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20-112323106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician