Provider Demographics
NPI:1598044828
Name:BRISTER, KATIE JANELLE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JANELLE
Last Name:BRISTER
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 1:504 EAST 24TH STREET
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3214
Mailing Address - Country:US
Mailing Address - Phone:903-815-0843
Mailing Address - Fax:
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:903-815-0843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580EMedicaid