Provider Demographics
NPI:1376856641
Name:MCCORKLE, DANETTE
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:MCCORKLE
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 1:1129 WESTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1619
Mailing Address - Country:US
Mailing Address - Phone:405-840-5278
Mailing Address - Fax:
Practice Address - Street 1:4436 NW 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2212
Practice Address - Country:US
Practice Address - Phone:405-858-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10Medicaid