Healthcare Provider Details

I. General information

NPI: 1174361802
Provider Name (Legal Business Name): MS. CANDY ANN MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

IV. Provider business mailing address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

V. Phone/Fax

Practice location:
  • Phone: 918-340-5503
  • Fax: 918-340-5505
Mailing address:
  • Phone: 918-340-5503
  • Fax: 918-340-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: