Provider Demographics
NPI:1437420866
Name:MASHBURN, MICHAEL LEON
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEON
Last Name:MASHBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19199 S 575 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1879
Mailing Address - Country:US
Mailing Address - Phone:918-931-1951
Mailing Address - Fax:
Practice Address - Street 1:19199 S 575 RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-1879
Practice Address - Country:US
Practice Address - Phone:918-931-1951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst