Provider Demographics
NPI:1851736920
Name:BREDEMEYER, SUSAN MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:BREDEMEYER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 700814
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-0814
Mailing Address - Country:US
Mailing Address - Phone:918-813-5255
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1075
Practice Address - Country:US
Practice Address - Phone:539-286-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10216101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid