Provider Demographics
NPI:1548605041
Name:CANTRELL, ANITA JOY (MDIV)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:JOY
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 912
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301
Mailing Address - Country:US
Mailing Address - Phone:918-256-7518
Mailing Address - Fax:918-256-6771
Practice Address - Street 1:1520 NORTH INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:918-256-7518
Practice Address - Fax:918-256-6771
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732380EMedicaid
OK100732380AMedicaid
OK100732380CMedicaid
OK100732380FMedicaid