Provider Demographics
NPI:1215261086
Name:BRENDA SUE MATHIS
Entity type:Organization
Organization Name:BRENDA SUE MATHIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:MAMFT
Authorized Official - Phone:918-698-7171
Mailing Address - Street 1:4034 W ROANOKE PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-1327
Mailing Address - Country:US
Mailing Address - Phone:918-698-7171
Mailing Address - Fax:
Practice Address - Street 1:4034 W ROANOKE PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-1327
Practice Address - Country:US
Practice Address - Phone:918-698-7171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK320800000X, 323P00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare UPIN