Provider Demographics
NPI:1437409588
Name:IVEY, BRANDI LINN (BS)
Entity Type:Individual
Prefix:MISS
First Name:BRANDI
Middle Name:LINN
Last Name:IVEY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S BROADWAY AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-5809
Mailing Address - Country:US
Mailing Address - Phone:405-831-9660
Mailing Address - Fax:
Practice Address - Street 1:6202 S LEWIS AVE STE H
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1064
Practice Address - Country:US
Practice Address - Phone:580-889-3399
Practice Address - Fax:580-889-3887
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid