Provider Demographics
NPI:1851678643
Name:BURRELL, DE'LICIA
Entity Type:Individual
Prefix:
First Name:DE'LICIA
Middle Name:
Last Name:BURRELL
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 1:1716 NORTH GLADE AVE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1716 N GLADE AVE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-5419
Practice Address - Country:US
Practice Address - Phone:580-212-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health