Provider Demographics
NPI:1609208719
Name:THELEN, TERRI (MA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:THELEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W LIBERTY RD.
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-4418
Mailing Address - Country:US
Mailing Address - Phone:303-345-7045
Mailing Address - Fax:
Practice Address - Street 1:905 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1652
Practice Address - Country:US
Practice Address - Phone:918-967-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5488101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200534390AMedicaid