Healthcare Provider Details

I. General information

NPI: 1063035871
Provider Name (Legal Business Name): STANA RAE SELF LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 N 4268 RD
HUGO OK
74743-6945
US

IV. Provider business mailing address

976 N 4268 RD
HUGO OK
74743-6945
US

V. Phone/Fax

Practice location:
  • Phone: 580-372-3535
  • Fax:
Mailing address:
  • Phone: 580-372-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10493
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: