Provider Demographics
NPI:1437313343
Name:BREWER, MARTHA (MS)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4208
Mailing Address - Country:US
Mailing Address - Phone:918-587-3888
Mailing Address - Fax:918-587-3894
Practice Address - Street 1:1608 S ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4208
Practice Address - Country:US
Practice Address - Phone:918-587-3888
Practice Address - Fax:918-587-3894
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK834101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200087380 AMedicaid