Healthcare Provider Details

I. General information

NPI: 1730536897
Provider Name (Legal Business Name): MS. CRYSTAL STAR MARIE ISAACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL RILEY

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6128 E 38TH ST
TULSA OK
74135-5832
US

IV. Provider business mailing address

6128 E 38TH ST
TULSA OK
74135-5832
US

V. Phone/Fax

Practice location:
  • Phone: 918-779-7144
  • Fax:
Mailing address:
  • Phone: 918-779-7144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12236
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: