Provider Demographics
NPI:1154614139
Name:WARE, MICQUEAL L
Entity type:Individual
Prefix:
First Name:MICQUEAL
Middle Name:L
Last Name:WARE
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 1:4400 COLTRANE PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73121-6606
Mailing Address - Country:US
Mailing Address - Phone:405-609-6169
Mailing Address - Fax:405-609-6169
Practice Address - Street 1:11032 QUAIL CREEK RD STE 212
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6220
Practice Address - Country:US
Practice Address - Phone:405-905-2074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OK5999101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst