Provider Demographics
NPI:1508226333
Name:DENSMAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DENSMAN
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:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-0000
Mailing Address - Country:US
Mailing Address - Phone:580-745-9610
Mailing Address - Fax:580-745-9891
Practice Address - Street 1:2600 W BROADWAY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-6509
Practice Address - Country:US
Practice Address - Phone:580-622-2783
Practice Address - Fax:580-622-5038
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708380Medicaid