Provider Demographics
NPI:1578563664
Name:CRAGAR, LISA M (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:CRAGAR
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 JO ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4013
Mailing Address - Country:US
Mailing Address - Phone:918-207-5700
Mailing Address - Fax:
Practice Address - Street 1:204 JO ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4013
Practice Address - Country:US
Practice Address - Phone:918-207-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT-7063183700000X
OK4142101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No183700000XPharmacy Service ProvidersPharmacy Technician