Provider Demographics
NPI:1609073725
Name:MERTENS, VADA ARLENE
Entity Type:Individual
Prefix:
First Name:VADA
Middle Name:ARLENE
Last Name:MERTENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VADA
Other - Middle Name:
Other - Last Name:ARLENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:407 16 BLVD SW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354
Mailing Address - Country:US
Mailing Address - Phone:918-542-7710
Mailing Address - Fax:
Practice Address - Street 1:407 16 BLVD SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354
Practice Address - Country:US
Practice Address - Phone:918-542-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10064510A320600000X
OK347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered347C00000XTransportation ServicesPrivate Vehicle