Provider Demographics
NPI:1710235973
Name:BOOKOUT, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:BOOKOUT
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 1:1500 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-1421
Mailing Address - Country:US
Mailing Address - Phone:580-335-3320
Mailing Address - Fax:580-335-7443
Practice Address - Street 1:1500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-1421
Practice Address - Country:US
Practice Address - Phone:580-335-3320
Practice Address - Fax:580-335-7443
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
OK598124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No124Q00000XDental ProvidersDental Hygienist