Provider Demographics
NPI:1184094914
Name:STONE, BRANDON DUANE (BACHELORS OF ARTS)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DUANE
Last Name:STONE
Suffix:
Gender:M
Credentials:BACHELORS OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17161 OLD HIGHWAY 112
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-7554
Mailing Address - Country:US
Mailing Address - Phone:918-413-9024
Mailing Address - Fax:
Practice Address - Street 1:1011 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2609
Practice Address - Country:US
Practice Address - Phone:918-649-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKJ082273380103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation