Provider Demographics
NPI:1417231168
Name:CASEY, MICHELLE (LADC MH)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:LADC MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S JT STITES BLVD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-9301
Mailing Address - Country:US
Mailing Address - Phone:918-775-7787
Mailing Address - Fax:
Practice Address - Street 1:210 S JT STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9301
Practice Address - Country:US
Practice Address - Phone:918-775-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK1361101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200383360BMedicaid