Provider Demographics
NPI:1760760417
Name:MASSEY, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:MASSEY
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 1:5350 S WESTERN AVE STE 734
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-4535
Mailing Address - Country:US
Mailing Address - Phone:405-474-6446
Mailing Address - Fax:
Practice Address - Street 1:9212 N KELLEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-2419
Practice Address - Country:US
Practice Address - Phone:405-255-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK5591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor