Healthcare Provider Details

I. General information

NPI: 1376954438
Provider Name (Legal Business Name): DEBORAUGH DE ANN ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24332 E 757 RD
TAHLEQUAH OK
74464-1949
US

IV. Provider business mailing address

24332 E 757 RD
TAHLEQUAH OK
74464-1949
US

V. Phone/Fax

Practice location:
  • Phone: 918-431-4514
  • Fax:
Mailing address:
  • Phone: 918-431-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VII. Legacy identifiers

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

# 1
IdentifierP00724340
Identifier TypeOTHER
Identifier State
Identifier IssuerPTIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: