Provider Demographics
NPI:1639836976
Name:CANALES SEBASTIAN, MAYRA GABRIELA (LCSW)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:GABRIELA
Last Name:CANALES SEBASTIAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 S FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6105
Mailing Address - Country:US
Mailing Address - Phone:573-356-2404
Mailing Address - Fax:
Practice Address - Street 1:2321 E 3RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-1831
Practice Address - Country:US
Practice Address - Phone:918-622-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical