Provider Demographics
NPI:1063714335
Name:PRATT, ROBERTA NICOLE
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:NICOLE
Last Name:PRATT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BOBBIE
Other - Middle Name:NICOLE
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:504 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3214
Mailing Address - Country:US
Mailing Address - Phone:903-815-0843
Mailing Address - Fax:580-371-9944
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:903-815-0843
Practice Address - Fax:580-371-9944
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746580EMedicaid