Healthcare Provider Details

I. General information

NPI: 1215261086
Provider Name (Legal Business Name): BRENDA SUE MATHIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4034 W ROANOKE PL
BROKEN ARROW OK
74011-1327
US

IV. Provider business mailing address

4034 W ROANOKE PL
BROKEN ARROW OK
74011-1327
US

V. Phone/Fax

Practice location:
  • Phone: 918-698-7171
  • Fax:
Mailing address:
  • Phone: 918-698-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateOK

VIII. Authorized Official

Name: MS. BRENDA SUE MATHIS
Title or Position: OWNER
Credential: MAMFT
Phone: 918-698-7171