Provider Demographics
NPI:1689760779
Name:ISAACSON, MARY KAY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:ISAACSON
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 1:3503 TIMBERLANE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-8461
Mailing Address - Country:US
Mailing Address - Phone:918-246-0080
Mailing Address - Fax:
Practice Address - Street 1:5930 E 31ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5114
Practice Address - Country:US
Practice Address - Phone:918-665-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT 412225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1007428860BMedicaid