Provider Demographics
NPI:1417593773
Name:BUCHANAN, MARIAH
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:BUCHANAN
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:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:SENTINEL
Mailing Address - State:OK
Mailing Address - Zip Code:73664-0194
Mailing Address - Country:US
Mailing Address - Phone:580-821-6970
Mailing Address - Fax:
Practice Address - Street 1:620 NW 5TH ST STE D
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-3947
Practice Address - Country:US
Practice Address - Phone:405-208-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator