Healthcare Provider Details

I. General information

NPI: 1841963329
Provider Name (Legal Business Name): MADISON MARIE THREET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17675 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5492
US

IV. Provider business mailing address

57200 E 336 RD
JAY OK
74346-5161
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-3243
  • Fax: 918-253-5737
Mailing address:
  • Phone: 918-801-1913
  • Fax: 918-253-5737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: