Provider Demographics
NPI:1356889745
Name:STACY, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:STACY
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 1:507 DRWEY
Mailing Address - Street 2:
Mailing Address - City:POTESU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-649-0172
Mailing Address - Fax:
Practice Address - Street 1:507 DRWEY
Practice Address - Street 2:
Practice Address - City:POTESU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-649-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM0801X405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional