Provider Demographics
NPI:1346395225
Name:VANNOSTRAND, RANDY RICK (MDIV, PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:RICK
Last Name:VANNOSTRAND
Suffix:
Gender:M
Credentials:MDIV, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 S SHERIDAN RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1141
Mailing Address - Country:US
Mailing Address - Phone:918-663-6057
Mailing Address - Fax:918-266-1695
Practice Address - Street 1:4530 S SHERIDAN RD
Practice Address - Street 2:SUITE 235
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-1141
Practice Address - Country:US
Practice Address - Phone:918-663-6057
Practice Address - Fax:918-266-1695
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK304101YA0400X
OK581101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional