Provider Demographics
NPI:1063789709
Name:SELF, MIJA
Entity type:Individual
Prefix:
First Name:MIJA
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:LEHIGH
Mailing Address - State:OK
Mailing Address - Zip Code:74556-0253
Mailing Address - Country:US
Mailing Address - Phone:580-298-2830
Mailing Address - Fax:
Practice Address - Street 1:813 N WILLOW
Practice Address - Street 2:
Practice Address - City:LEHIGH
Practice Address - State:OK
Practice Address - Zip Code:74523
Practice Address - Country:US
Practice Address - Phone:580-378-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X, 103K00000X
OK7171101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst