Provider Demographics
NPI:1568819241
Name:CHOUDRY, MANSUR O (BCBA)
Entity Type:Individual
Prefix:MR
First Name:MANSUR
Middle Name:O
Last Name:CHOUDRY
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:MR
Other - First Name:MANSUR
Other - Middle Name:
Other - Last Name:CHOUDRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1208 ALEXANDERS TRL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-4373
Mailing Address - Country:US
Mailing Address - Phone:405-361-7915
Mailing Address - Fax:405-752-8963
Practice Address - Street 1:12201 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8022
Practice Address - Country:US
Practice Address - Phone:405-752-5112
Practice Address - Fax:405-752-8963
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-10-6911103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst