Provider Demographics
NPI:1407388861
Name:BRACKEEN, MICHAEL (MS CCC SLP/L)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BRACKEEN
Suffix:
Gender:M
Credentials:MS CCC SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6261
Mailing Address - Country:US
Mailing Address - Phone:405-437-5048
Mailing Address - Fax:
Practice Address - Street 1:3017 N STILES AVE STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2805
Practice Address - Country:US
Practice Address - Phone:405-271-9477
Practice Address - Fax:405-271-9479
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist