Provider Demographics
NPI:1770828006
Name:BURROUGH, CRYSTAL MELRISE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MELRISE
Last Name:BURROUGH
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 1:2817 SHADYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-3121
Mailing Address - Country:US
Mailing Address - Phone:405-824-8062
Mailing Address - Fax:
Practice Address - Street 1:10948 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6224
Practice Address - Country:US
Practice Address - Phone:405-751-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid