Provider Demographics
NPI:1639402894
Name:FUGATT, CYNTHIA ANNE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANNE
Last Name:FUGATT
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 1:6720 S PEORIA AVE APT 823
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3648
Mailing Address - Country:US
Mailing Address - Phone:918-794-4296
Mailing Address - Fax:
Practice Address - Street 1:2725 E SKELLY DR
Practice Address - Street 2:SW 202
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6241
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:918-382-7302
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00000000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSOCIAL SECURITY NUMBER