Provider Demographics
NPI:1518238302
Name:OSBURN, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:OSBURN
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 1:6937 S 161ST WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-2927
Mailing Address - Country:US
Mailing Address - Phone:918-284-1018
Mailing Address - Fax:
Practice Address - Street 1:6937 S 161ST WEST AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-2927
Practice Address - Country:US
Practice Address - Phone:918-284-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid