Healthcare Provider Details

I. General information

NPI: 1063347821
Provider Name (Legal Business Name): CARRIE MATHERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2212 WESTPARK DR
NORMAN OK
73069-4097
US

IV. Provider business mailing address

609 SW 113TH ST
OKLAHOMA CITY OK
73170-5813
US

V. Phone/Fax

Practice location:
  • Phone: 405-857-7624
  • Fax:
Mailing address:
  • Phone: 405-620-3153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLFMTCANDIDATE13420
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: