Provider Demographics
NPI:1811636772
Name:HEADRICK, MYKEL ANN (CM2)
Entity type:Individual
Prefix:MRS
First Name:MYKEL
Middle Name:ANN
Last Name:HEADRICK
Suffix:
Gender:F
Credentials:CM2
Other - Prefix:
Other - First Name:MYKEL
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CM2
Mailing Address - Street 1:704 S OKLAHOMA ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-5048
Mailing Address - Country:US
Mailing Address - Phone:918-724-5094
Mailing Address - Fax:
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-227-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator