Provider Demographics
NPI:1841623444
Name:SUMMERS, MARY E (BS/BHRS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:BS/BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 W DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2183
Mailing Address - Country:US
Mailing Address - Phone:918-361-4664
Mailing Address - Fax:800-260-7966
Practice Address - Street 1:4122 W 55TH PLACE S.
Practice Address - Street 2:SUITE 119
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-9108
Practice Address - Country:US
Practice Address - Phone:918-486-9996
Practice Address - Fax:800-260-7966
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBHRS CERTIFICATION225C00000X
OK6100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid