Provider Demographics
NPI:1508624693
Name:FARRELL, MARDIETH A
Entity Type:Individual
Prefix:
First Name:MARDIETH
Middle Name:A
Last Name:FARRELL
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 1:432057 STATE HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:FORT TOWSON
Mailing Address - State:OK
Mailing Address - Zip Code:74735-7506
Mailing Address - Country:US
Mailing Address - Phone:580-372-6516
Mailing Address - Fax:580-209-6179
Practice Address - Street 1:1402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2059
Practice Address - Country:US
Practice Address - Phone:580-209-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician