Provider Demographics
NPI:1417473521
Name:BACON, CHELSYE R (CMII)
Entity Type:Individual
Prefix:
First Name:CHELSYE
Middle Name:R
Last Name:BACON
Suffix:
Gender:F
Credentials:CMII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 E INDIAN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7939
Mailing Address - Country:US
Mailing Address - Phone:580-756-7383
Mailing Address - Fax:
Practice Address - Street 1:5401 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-7602
Practice Address - Country:US
Practice Address - Phone:405-686-7828
Practice Address - Fax:405-686-7827
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK318512251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200879420KMedicaid