Provider Demographics
NPI:1285079525
Name:MIKUS, SURAYA LYNN
Entity type:Individual
Prefix:
First Name:SURAYA
Middle Name:LYNN
Last Name:MIKUS
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 1:1202 E 57TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7815
Mailing Address - Country:US
Mailing Address - Phone:918-808-4062
Mailing Address - Fax:
Practice Address - Street 1:1700 E 141ST ST
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-3807
Practice Address - Country:US
Practice Address - Phone:918-291-4230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK872225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist