Provider Demographics
NPI:1821424516
Name:KIRK, ROSE MARY
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:KIRK
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 1:431 MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061
Mailing Address - Country:US
Mailing Address - Phone:918-332-8718
Mailing Address - Fax:
Practice Address - Street 1:431 MORTON AVE
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:OK
Practice Address - Zip Code:74061
Practice Address - Country:US
Practice Address - Phone:918-332-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK736017987104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$OtherSSN