Healthcare Provider Details

I. General information

NPI: 1396947305
Provider Name (Legal Business Name): ROBERTA SUE HEUSTIS LADC, (US)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 E ADMIRAL PL
TULSA OK
74110-5436
US

IV. Provider business mailing address

18921 W WEKIWA RD LOT 31
SAND SPRINGS OK
74063-5970
US

V. Phone/Fax

Practice location:
  • Phone: 918-835-3017
  • Fax: 918-836-0358
Mailing address:
  • Phone: 918-981-0833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: