Provider Demographics
NPI:1790523132
Name:UPSHAW, MISTY (LMSW PROVISIONAL)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:LMSW PROVISIONAL
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:MCGEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW PROVISIONAL
Mailing Address - Street 1:1608 S ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4208
Mailing Address - Country:US
Mailing Address - Phone:918-587-3888
Mailing Address - Fax:
Practice Address - Street 1:1608 S ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4208
Practice Address - Country:US
Practice Address - Phone:918-587-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21067-P104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker