Provider Demographics
NPI:1568838597
Name:FOUTCH, MISTY (MA, BHCM II)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:FOUTCH
Suffix:
Gender:F
Credentials:MA, BHCM II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26243 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-8740
Mailing Address - Country:US
Mailing Address - Phone:918-614-0778
Mailing Address - Fax:918-999-0109
Practice Address - Street 1:26243 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-8740
Practice Address - Country:US
Practice Address - Phone:918-614-0778
Practice Address - Fax:918-999-0109
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator