Healthcare Provider Details

I. General information

NPI: 1720287428
Provider Name (Legal Business Name): DEANDRIA ELAINE RIDEAU PSYCHOTHERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 TURTLE CREEK DR
CHOCTAW OK
73020-7433
US

IV. Provider business mailing address

2701 N OKLAHOMA AVE
OKLAHOMA CITY OK
73105-2724
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-5620
  • Fax: 405-848-5619
Mailing address:
  • Phone: 405-528-8686
  • Fax: 405-528-8692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: