Healthcare Provider Details

I. General information

NPI: 1740822493
Provider Name (Legal Business Name): ANDREA COUSPARIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 W BROADWAY ST
MUSKOGEE OK
74401-2761
US

IV. Provider business mailing address

2310 W BROADWAY ST
MUSKOGEE OK
74401-2761
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-7210
  • Fax:
Mailing address:
  • Phone: 918-682-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number21080
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: