Provider Demographics
NPI:1326283466
Name:CROOKEDACRE, DENNIS CHARLES
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:CHARLES
Last Name:CROOKEDACRE
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 1:2990 N SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3700
Mailing Address - Country:US
Mailing Address - Phone:918-342-2622
Mailing Address - Fax:918-342-2641
Practice Address - Street 1:8937 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6004
Practice Address - Country:US
Practice Address - Phone:918-872-9777
Practice Address - Fax:918-872-9779
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010401101YP2500X
OK4471101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4471OtherLICENSE