Provider Demographics
NPI:1114791241
Name:KRUTA, TIARA DONN MCKENSIE
Entity type:Individual
Prefix:
First Name:TIARA DONN
Middle Name:MCKENSIE
Last Name:KRUTA
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 1:13501 SE 29TH ST TRLR 121
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6652
Mailing Address - Country:US
Mailing Address - Phone:405-305-7210
Mailing Address - Fax:
Practice Address - Street 1:105828 S PARKWOOD MEADOWS DR
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851-9683
Practice Address - Country:US
Practice Address - Phone:405-305-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
OK12041101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional