Provider Demographics
NPI:1780018937
Name:RAYMO, MISTY MARIE
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MARIE
Last Name:RAYMO
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 1:216 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-6628
Mailing Address - Country:US
Mailing Address - Phone:580-993-0784
Mailing Address - Fax:
Practice Address - Street 1:216 W 14TH ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-6628
Practice Address - Country:US
Practice Address - Phone:580-993-0784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708380Medicaid
OK200049040Medicaid