Provider Demographics
NPI:1811206394
Name:HANRAHAN, MISTI D (MSW, MHP)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:D
Last Name:HANRAHAN
Suffix:
Gender:F
Credentials:MSW, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4734
Mailing Address - Country:US
Mailing Address - Phone:918-458-0113
Mailing Address - Fax:
Practice Address - Street 1:1008 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4734
Practice Address - Country:US
Practice Address - Phone:918-458-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker