Healthcare Provider Details

I. General information

NPI: 1083433569
Provider Name (Legal Business Name): AUDREY ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDREY CUNNINGHAM

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4416 W HOUSTON ST
BROKEN ARROW OK
74012-4645
US

IV. Provider business mailing address

4416 W HOUSTON ST
BROKEN ARROW OK
74012-4645
US

V. Phone/Fax

Practice location:
  • Phone: 918-288-0027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: