Provider Demographics
NPI:1629468723
Name:COBURN, VELICIA
Entity Type:Individual
Prefix:
First Name:VELICIA
Middle Name:
Last Name:COBURN
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 1:405 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-4052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4710 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-4052
Practice Address - Country:US
Practice Address - Phone:405-326-3806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health