Provider Demographics
NPI:1760815187
Name:MCENTIRE UPHOLD, BRENDA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MCENTIRE UPHOLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:MCENTIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:8703 W 151ST ST S
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-1043
Mailing Address - Country:US
Mailing Address - Phone:316-305-6064
Mailing Address - Fax:855-551-4090
Practice Address - Street 1:3015 E SKELLY DR STE 211-4
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:316-305-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200531130AMedicaid