Provider Demographics
NPI:1649837691
Name:ROUBIDOUX, TENISE
Entity type:Individual
Prefix:
First Name:TENISE
Middle Name:
Last Name:ROUBIDOUX
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 1:500 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-2422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-2422
Practice Address - Country:US
Practice Address - Phone:866-926-6552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK251S00000XMedicaid