MEDICARE: SALLY RAY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1529	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	585566455002	OTHER	OK	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1285825356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALLY RAY INC

Provider Business Mailing Address
First Line	:	5009 N PENN AVE STE 116
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8888
Country	:	US
Telephone Number	:	405-636-9855
Fax Number	:	405-879-2388

Provider Business Practice Location Address
First Line	:	5009 N PENN AVE STE 116
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8888
Country	:	US
Telephone Number	:	405-636-9855
Fax Number	:	405-879-2388

Authorized Official
Title or Position	:	LICENSED CLINICAL SOC. WORKER/OWNER
Name	:	SALLY R RAY
Credential	:	LCSW
Telephone Number	:	405-636-9855

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/31/2007

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Directions to “SALLY RAY INC ” Practice Location

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