Provider Demographics
NPI:1508137688
Name:MBACKE, ASTOU STAR (BHRS)
Entity Type:Individual
Prefix:
First Name:ASTOU
Middle Name:STAR
Last Name:MBACKE
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-3322
Mailing Address - Country:US
Mailing Address - Phone:918-298-5059
Mailing Address - Fax:918-298-3869
Practice Address - Street 1:2921 E 91ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-3322
Practice Address - Country:US
Practice Address - Phone:918-298-5059
Practice Address - Fax:918-298-3869
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health