Provider Demographics
NPI:1689952129
Name:MUSTAFINA, SUSAN LEIGH (MED)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:MUSTAFINA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33007 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-3429
Mailing Address - Country:US
Mailing Address - Phone:405-395-7548
Mailing Address - Fax:
Practice Address - Street 1:905 E WILSON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4165
Practice Address - Country:US
Practice Address - Phone:405-214-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200362320BMedicaid