Provider Demographics
NPI:1962863977
Name:MCCLURE, MINA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MINA
Middle Name:
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:KAWASAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11870 N 107TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-5537
Mailing Address - Country:US
Mailing Address - Phone:918-431-1078
Mailing Address - Fax:
Practice Address - Street 1:2552 E KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014
Practice Address - Country:US
Practice Address - Phone:918-893-3735
Practice Address - Fax:918-893-3745
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist