Provider Demographics
NPI:1912141813
Name:BRACE, MARVIN RAY JR (CADC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:RAY
Last Name:BRACE
Suffix:JR
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W 5TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4056
Mailing Address - Country:US
Mailing Address - Phone:405-743-1968
Mailing Address - Fax:405-743-1595
Practice Address - Street 1:217 W 5TH AVE STE 7
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4056
Practice Address - Country:US
Practice Address - Phone:405-743-1968
Practice Address - Fax:405-743-1595
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK161101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)