Provider Demographics
NPI:1750660254
Name:HEARD, ANDRE T
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:T
Last Name:HEARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7021 BRIARCREEK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-7232
Mailing Address - Country:US
Mailing Address - Phone:405-886-2365
Mailing Address - Fax:
Practice Address - Street 1:7021 BRIARCREEK DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-7232
Practice Address - Country:US
Practice Address - Phone:405-886-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK080938444251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKK080938444Medicaid