Provider Demographics
NPI:1669118238
Name:MICHENER, LAURA RANAE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:RANAE
Last Name:MICHENER
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:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74402-1267
Mailing Address - Country:US
Mailing Address - Phone:918-380-0104
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1267
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74402-1267
Practice Address - Country:US
Practice Address - Phone:918-380-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20925-P101YA0400X
1041S0200X, 106S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator