Provider Demographics
NPI:1770975385
Name:AUSTIN, PHILISHA J (MED, CADC)
Entity type:Individual
Prefix:MRS
First Name:PHILISHA
Middle Name:J
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:MED, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-0185
Mailing Address - Country:US
Mailing Address - Phone:918-567-2905
Mailing Address - Fax:918-567-2995
Practice Address - Street 1:13597 SE 202ND RD
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-6003
Practice Address - Country:US
Practice Address - Phone:918-567-2905
Practice Address - Fax:918-567-2995
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK322324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility