Provider Demographics
NPI:1437871779
Name:SIQUEIROS, EZY
Entity Type:Individual
Prefix:
First Name:EZY
Middle Name:
Last Name:SIQUEIROS
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 1:6941 S JOPLIN AVE APT 1210
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3541
Mailing Address - Country:US
Mailing Address - Phone:918-851-6937
Mailing Address - Fax:
Practice Address - Street 1:3124 E APACHE ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-2320
Practice Address - Country:US
Practice Address - Phone:918-508-2717
Practice Address - Fax:918-508-2788
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker