Provider Demographics
NPI:1295054567
Name:DRY, STACEY RENEE
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:RENEE
Last Name:DRY
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 1:32890 S 321ST WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-4215
Mailing Address - Country:US
Mailing Address - Phone:918-367-6485
Mailing Address - Fax:
Practice Address - Street 1:32890 S 321ST WEST AVE
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-4215
Practice Address - Country:US
Practice Address - Phone:918-367-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK235026101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool