Provider Demographics
NPI:1538463468
Name:MICHELLE RAYBURN, LCSW, PLLC
Entity Type:Organization
Organization Name:MICHELLE RAYBURN, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-202-1331
Mailing Address - Street 1:5015 N PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8891
Mailing Address - Country:US
Mailing Address - Phone:405-202-1331
Mailing Address - Fax:405-796-7260
Practice Address - Street 1:5015 N PENNSYLVANIA AVE
Practice Address - Street 2:SUITE # 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8891
Practice Address - Country:US
Practice Address - Phone:405-202-1331
Practice Address - Fax:405-796-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK3673251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health