Provider Demographics
NPI:1578823233
Name:CRAIN, BRENDA RAQUEL
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:RAQUEL
Last Name:CRAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 SW 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7696
Mailing Address - Country:US
Mailing Address - Phone:405-570-3139
Mailing Address - Fax:
Practice Address - Street 1:8901 S SANTA FE AVE STE E
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8413
Practice Address - Country:US
Practice Address - Phone:405-605-5757
Practice Address - Fax:405-605-5775
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK189357L101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor