Healthcare Provider Details

I. General information

NPI: 1023652385
Provider Name (Legal Business Name): KRISTIN ALAINE MACKEY MS, LADC CANDIDATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 S SHERIDAN RD STE 106
TULSA OK
74145-5715
US

IV. Provider business mailing address

4815 S SHERIDAN RD STE 106
TULSA OK
74145-5715
US

V. Phone/Fax

Practice location:
  • Phone: 918-500-1024
  • Fax:
Mailing address:
  • Phone: 918-500-1024
  • Fax: 918-209-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number434
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: