Provider Demographics
NPI:1790042588
Name:SWOBODA-WIEDEL, MARTINA LUISE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:LUISE
Last Name:SWOBODA-WIEDEL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-382-1285
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-382-1285
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK52401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor