Provider Demographics
NPI:1295821460
Name:KOETTER-MANSON, MARCI LYNN (LSWA)
Entity type:Individual
Prefix:MS
First Name:MARCI
Middle Name:LYNN
Last Name:KOETTER-MANSON
Suffix:
Gender:F
Credentials:LSWA
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 490
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070
Mailing Address - Country:US
Mailing Address - Phone:405-307-2814
Mailing Address - Fax:405-307-2801
Practice Address - Street 1:2002 E ROBINSON
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071
Practice Address - Country:US
Practice Address - Phone:405-307-2814
Practice Address - Fax:405-307-2801
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK586104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker